
Class "fiMva 

Book . 

OopigM 



COPYRIGHT DEPOSIT; 



The Care of the Insane 



AND 



Hospital Management 



BY 

CHARLES WHITNEY PAGE, M.D. 

i\ 

Assistant Physician Hartford Retreat, Hartford, Connecticut 
1871 to 1872 and 1873 to 1888 

Superintendent Connecticut Hospital for the Insane, Middletown 
1898 to 1901 

Superintendent Danvers State Hospital, Danvers, Massachusetts 
1888 to 1898 and 1903 to 1910 

Member of The American Medico-Psychological Association 

The Boston Society of Psychiatry and Neurology 

The New England Psychiatric Society 

The Massachusetts Medical Society 



BOSTON 

W. M. LEONARD, Publisher 
1912 



CONTENTS. 

Page 
Introduction. — Non-mechanical restraint of the insane. — Con- 
ditions essential to its success 9 

Hospital Trustees. — Method of selection. — Representative 
ability and character important. — Trustee duties, responsi- 
bilities and opportunities 15 

Superintendent. — Necessary qualifications of the man. — Im- 
portance of wise discipline and high ideals. — Social and 
official duties 33 

Assistant Physicians. — Discrimination in selection important. 

— Promotions. — Obligations assumed. — Official duties. — 
Advantageous#facilities for professional development 57 

Laboratory — Its importance and prospects. — Superior advan- 
tages in hospitals for the insane 73 

Management of Patients. — What " non-restraint" stands for. 

— Methods of treatment should vary to meet needs of dif- 
ferent cases and classes. — Obviating restraint better than 
condemning it. — Patients' visitors. — Congregate dining 
room 79 

Attendants and Nurses. — Characteristics of many candidates. 

— Difficult duties. — Prime necessity for self -discipline. — ■ 
Intelligent sympathy the keynote. — A case showing how 
kindness, tact and perseverance win. — Moral elevation 
result of humane effort. — Coping with insane patients devel- 
ops the nurse's mental ability and moral character. — The 
inducements of high ideals properly presented 105 

Appendix. — Managing a case without restraint. — The impor- 
tance of the card index in hospitals 133 



INTRODUCTION. 

Insanity is the most grievous malady ever inflicted 
upon mankind. Unable to observe accurately or to 
reason correctly, the insane man's narrow, ego-centric 
world quickly alienates him from his normal associations 
and interrupts habitual lines of conduct. The resulting 
aimless, erratic or hazardous manifestations bring upon 
him antagonism and too frequently cruel abuse. Thanks 
to science and advancing civilization, his treatment in 
modern times has been radically changed for the better. 
But of those familiar with hospital conditions as they 
exist to-day, few, if any, would venture to assert that 
the custodial management of the so-called violent insane 
is wholly satisfactory, or that the highest standards of 
moral and scientific treatment have been universally 
adopted. 

Notwithstanding it is now more than a century 
since satisfactory results were obtained by managing 
the insane without restraining their actions through the 
use of mechanical apparatus, it is to be feared that a 
majority of those medical and non-medical individuals 
who have been responsible for or engaged in the treat- 
ment and care of the insane have not fully comprehended 

9 



IO CARE OF THE INSANE " 

just what the "non-restraint "system of managing the in- 
sane comprises. Pinel in France, Tuke, Hill and Conolly 
in England, were the pioneers in this humane method. 
Dr. Conolly, superintendent of the insane asylum at 
Hanwell, England, through his devotion to the cause, 
his speech and writings on this subject, and his con- 
spicuous success without restraint in a large institu- 
tion for the care of the insane, forced the question of 
" non-restraint " upon public attention. He not only 
fostered " non-restraint" ideas and developed the sys- 
tem for the benefit of patients under his immediate care, 
but he utilized his experience and success as an object 
lesson to other superintendents for the benefit of the 
insane wherever confined and for all time. Conolly, 
having thoroughly mastered the many details and prob- 
lems involved in conducting a large public institution 
for the insane on the " non-restraint" basis, was justi- 
fied in expressing the following sweeping and well- 
considered convictions upon this subject, viz.: "After 
five years' experience with the non-restraint system, I 
have no hesitation in recording my opinion that with a 
well-constituted governing body, animated by philan- 
thropy, directed by intelligence and acting by means 
of proper officers, there is no asylum in the world in 
which all mechanical restraint may not be abolished, 
not only with safety, but with incalculable advantage." 



CARE OF THE INSANE II 

While a few prominent hospital superintendents have, 
since Conolly's day, openly condemned his methods, 
scoffed at his claims or questioned his judgment, doubt- 
less a majority of those responsible for the management 
of the insane have regarded his ideas as extreme, and 
many have viewed absolute "non-restraint" as imprac- 
ticable. In explanation of this opposition and indif- 
ference, it may be considered probable that those who 
have been antagonistic to the system of " non-restraint " 
failed to apprehend Conolly's viewpoint. Doubtless 
many hospital officials acting upon a superficial concep- 
tion of Conolly's practice have regarded the elimina- 
tion of mechanical appliances, strait-jackets, wristlets, 
bed harnesses, etc., as the object sought; whereas, he 
used the term "non-restraint" to characterize a com- 
prehensive non-coercive method of dealing with the 
insane. He had in mind a broad, complete system of 
hospital management so saturated with the spirit of 
"non-restraint," and so actuated by kindness, patience, 
consideration and tact, that the insane would not be 
provoked into acts of physical resistance, consequently 
situations or conditions suggesting the necessity for 
restraint would seldom arise. Those who have under- 
stood his theories and his practice so imperfectly as 
to suppose they had accomplished the ends he aimed 
at when they avoided the application of mechanical 



12 CARE OF THE INSANE 

devices through severe discipline, harsh, intimidating 
treatment of excitable and obstinate patients, or by the 
use of chemical agents, have naturally enough failed 
to discover any value or merit in " non-restraint.' ' 
Other worthy hospital administrators have no doubt 
been so engrossed in the study of scientific questions 
pertaining to mental disease and pathology that they 
have simply failed to give sufficient attention to the 
humane, social and moral elements which are funda- 
mental considerations of the true " non-restraint " mo- 
tive. Did the successful adoption of the ' ' non-restraint ' ' 
principle in hospitals for the insane depend simply upon 
official edicts forbidding the employment of old-time 
mechanical instruments of restraint, unquestionably hos- 
pital authorities would universally prefer the more hu- 
mane form of treatment. 

That Conolly understood what it signifies to man- 
age a hospital for the insane successfully on "non-re- 
straint" lines is shown by his declaration in which he 
specifies four conditions that are essential to success. 
These requisites are, first, "a well-constituted govern- 
ing body"; second, such a body "animated by phil- 
anthropy"; third, philanthropy "directed by intelli- 
gence"; and, fourth, "proper officers" — an executive 
force of assistants and nurses responsive to the high- 
est hospital ideals, which must be entertained and per- 



CARE OF THE INSANE 1 3 

sistently inculcated by the superintendent. When we 
realize that thousands of inexperienced men and women 
yearly join the nursing staff in state hospitals, that 
young medical men are constantly entering such insti- 
tutions to assume official duties, and that a large num- 
ber of private citizens — ladies and gentlemen — are 
annually appointed to serve on visiting committees or 
supervisory and directing boards in connection with 
such public institutions, we can appreciate the neces- 
sity for a comprehensive statement in the form of 
a manual or handbook from which interested persons 
can obtain a working knowledge of the best hospital 
methods and possibilities, and can qualify themselves 
to analyze hospital conditions as they find them, or 
trace to their obscure origin or cause intruding results 
which may demand attention. In the absence of such 
a printed guide, these official recruits are unable to 
adjust themselves correctly to hospital duties or to 
early satisfy a personal desire to promote as fully as 
possible true philanthropy in this most promising and 
too much neglected field. 

Having had thirty-five years' service as a medical 
officer in hospitals for the insane, much of his effort in 
later years having been given to the practical elabora- 
tion of methods employed by Dr. Conolly, the writer 
has been persuaded that his experience and observa- 



14 CARE OF THE INSANE 

tions, concisely stated, may be of service to those who 
desire a fuller knowledge of the internal workings of 
institutions where " non-restraint" is the practice. He 
therefore respectfully submits, to whom it may concern, 
his established convictions regarding the management 
of institutions which care for the insane. 



"A WELL-CONSTITUTED GOVERNING BODY." 

A medical superintendent thoroughly qualified to fill 
the position of executive head of an institution for the 
insane, and ambitious to rank with advanced men in 
his profession, may, if he attempts to manage the pa- 
tients under his charge in accordance with " non- 
restraint" ideals, have his good intentions frustrated 
by conditions beyond his control. The most formi- 
dable obstacle to his success that can possibly confront 
him, especially in the beginning, is a badly constituted 
governing body, unsympathetic or antagonistic trustees, 
a board chiefly interested in securing the objects which 
political interests deem important, or unwilling to as- 
sume responsibilities for those purposes which appeal 
mainly to humane sentiments. If the members of a 
board hold positive notions favoring the employment 
of mechanical restraint, the superintendent cannot pru- 
dently disregard their well-known conceptions on this 
important matter, and he may discover that his faculty 
for stating things or his powers of persuasion fail to 
convince them that " non-restraint" is feasible or worth 
the special efforts necessary to manage patients without 
using mechanical instruments for restraint. 

is 



1 6 CARE OF THE INSANE 

When Conolly referred to "a well-constituted gov- 
erning body" as something essential to success with 
" non-restraint " treatment of the insane, he had in 
mind, no doubt, the failure of his immediate predeces- 
sors, Drs. Charlesworth and Hill. They were medical 
superintendents and had satisfied themselves that Tuke's 
" non-restraint" treatment of insane patients at the 
York Retreat was not only a sane but a safe system, 
and should be the common practice in all hospitals for 
the insane. Yet in their own hospital wards its appli- 
cation in detail was only partially successful owing to the 
opposition of the governing boards under which they 
held office. Because injudicious and absurdly opin- 
ionated persons are sometimes found on boards of 
trustees and may unwisely overrule the better judg- 
ment of a superintendent, the proposal to abolish such 
governing bodies cannot be seriously considered, al- 
though such a step has been suggested in some parts 
of this country. A superintendent constantly feels the 
need of official advice and should be thankful when a 
board in a friendly spirit points out defective or faulty 
decision, errors liable to happen even to the best men. 
Then, under a democratic form of government, there 
seems a necessity for a duly appointed board to control 
the general affairs of each public institution; to hold 
real and personal property for the state; to appoint 



CARE OF THE INSANE 17 

the executive officers; to formulate or sanction rules of 
management; to supervise the entire plant and repre- 
sent officially and legally the state's interests as occasion 
may require. 

The scope of their powers and the peculiar respon- 
sibilities which trustees must assume suggest the im- 
portance of exercising especial care in their selection. 
And yet positions on such boards are generally obtained 
through the favor of the predominant political party, or 
its highest state representative. Often political con- 
siderations decide the character of such important 
boards. And boards thus chosen are virtually respon- 
sible to the community at large for the operations of 
broad, altruistic schemes based upon the most refined 
phases of pure philanthropy. Doubtless institution 
trustees as a rule intend to discharge their responsible 
duties honestly and exercise a fair degree of intelligence 
in doing so. But there are exceptional instances, and 
it is believed that many individual trustees, occasion- 
ally at least, entirely misunderstand the legitimate 
field for their activities. This is especially true of 
those appointees who receive such hospital positions 
as a reward for political service. 

It is not surprising that trustees enter upon their 
institutional duties with erroneous conceptions in re- 
spect to their official functions and privileges, since the 



1 8 CARE OF THE INSANE 

province of the hospital trustee is so ill denned by 
statutes that personal interpretation or inclination may 
naturally enough measure a trustee's conjecture as to 
his authority and prerogative. While a trustee now 
and then may make mistakes in beginning his public 
service with misdirected zeal, the great majority de- 
liberate too long before taking an active part in the 
hospital work. 

Hospital trustee boards are open to criticism chiefly 
through the neglect of their members to study the 
problems really involved in the work they presume to 
supervise. This common indifference to duties volun- 
tarily assumed, or carelessness in such respects, may be 
charged in most cases to the fact that these boards — 
these supervising or directing units — are each com- 
posed of several members, varying in number; conse- 
quently individual responsibility is so divided that any 
one member may easily estimate his own share as of 
little account, arguing that he constitutes but a frac- 
tional part of the organization. This inactive, ineffi- 
cient way of discharging their official obligations is 
especially true of the new and less prominent members of 
a board where one or two of longer experience unhesi- 
tatingly assume to possess complete knowledge of in- 
stitution affairs and a mastery of the situation. Thus, 
through the modesty and tacit consent of the other 



CARE OF THE INSANE 19 

members, practically a single individual on the board 
often controls the policy of an institution. 

With a purpose to obviate the faults of divided re- 
sponsibility and a hope of fancied gain through sys- 
tematizing conditions in the various institutions of the 
state, a general commission with one supervising mem- 
ber has been proposed as a substitute for the usual 
local boards. Considered superficially, this method 
would seem to insure a more complete and careful 
oversight and a keener sense of official responsibility. 
But under such an arrangement the commissioner 
might be inclined or forced to devote either too little or 
too much attention to any one hospital. If attached to 
but one or two, he could scarcely fail to trench upon the 
executive field, overshadowing the superintendent and 
thus dispossessing him of incentive and pride in his 
official duties. If in control of a group of institutions, 
his attention would extend over such a wide field of 
activities that he would be unable to follow out details 
and be obliged to depend upon the several superin- 
tendents for information, virtually accepting their ob- 
servations and adopting their suggestions, or he would 
enforce upon all institutions a common system of man- 
agement that would operate to suppress local ambi- 
tions and eliminate hospital individuality. Machine 
methods and standards are never conducive to prog- 



20 CARE OF THE INSANE 

ress in the domain of science or philanthropy, and 
when applied to the public institutions of the state will 
possibly foster political schemes. 

Reasons may be adduced why the supplies of several 
public institutions should be obtained by a central 
commission, but economy should not be expected as 
the natural result of thus concentrating official pur- 
chases. In his report to the State Charities Aid Asso- 
ciation, 1 Mr. H. C. Wright demonstrates that the more 
complete and rigid the system of central control over 
purchases in state institutions, the greater the discom- 
fiture of local officials, and where the cost of such cen- 
tral control is included in the cost of maintenance 
financial results the opposite of economy are reached. 
His conclusions are based upon a thorough study of 
conditions in New York and Iowa, where four slightly 
varying systems of central purchasing agencies are in 
operation. 

The ideal hospital board should be composed of 
carefully selected men residing within the hospital dis- 
trict, each one a prominent representative of some 
profession or business interest. The best judgment 
obtainable in the hospital locality should thus be at the 
service of the state, as it can be obtained gratis if the 

1 Report on Methods of Fiscal Control of State Institutions. 
Henry C. Wright. New York, 19 10. 



CARE OF THE INSANE 21 

appointing powers will ignore political influence and 
select for such honorary positions only citizens of estab- 
lished reputation in respect to ability, judgment and 
character. The expert knowledge collectively possessed 
by a board thus constituted would safeguard the inter- 
ests of the state, as well as those of its wards, and be 
gladly welcomed by all superintendents, as the daily 
management of the usual state hospital calls into req- 
uisition special knowledge in many professional and 
business lines. Then the whole field of institutional 
activities is certain to be examined and criticized by a 
properly interested public, and the probabilities are 
that every step in hospital work and development will 
be examined and criticized by outside judges, each ex- 
pert in his own line of activities. In this way, sooner 
or later, whatever is accomplished will be gauged 
according to the highest standards in each particular 
department. 

The laws of the state, their import and application 
to altered circumstances and new conditions, call for 
frequent interpretation. Medical questions are ever 
pressing for consideration and their solution calls for 
scientific knowledge in medicine, surgery, dietetics, psy- 
chiatry, etc. Engineering problems in connection with 
construction, heating, ventilation, water supply, sewage 
disposal constantly appear. Connected with many 



22 CARE OF THE INSANE 

hospitals is a farm department which will not escape 
the critical attention of the agricultural public unless 
it is conducted upon advanced theories regarding stock 
raising, milk production, crop rotation, truck farming, 
etc. With such burdensome duties always on hand 
to test the common sense and technical knowledge of 
hospital trustees and superintendents, the importance of 
securing for service on each institution board a promi- 
nent lawyer, a scientific physician, an able engineer or 
contractor, a public-spirited business man experienced 
in general affairs, a practical farmer, or similar recog- 
nized leaders in other business pursuits, would seem to 
be sufficiently obvious to create a strong, compelling 
public sentiment, influencing, if not controlling, such 
appointments. 

The addition to hospital boards of one or more 
ladies possessing keen perceptions, broad sympathies 
and balanced judgment insures a more careful consid- 
eration of the social aspects of institutional life and 
service, much of which might otherwise escape official 
attention. 

By virtue of their office, hospital trustees must expect 
to carry heavy responsibilities, and they should live up 
to the requirements of the position faithfully and cheer- 
fully. They must arbitrate the often conflicting inter- 
ests of the public, the executive officers and the state 



CARE OF THE INSANE 23 

wards. Therefore, they should weigh well their deci- 
sions, which may produce some unforeseen results. It 
is their duty to determine the practical boundaries of 
public disbursements and to adjust the economical 
expenditure of state funds. They must discriminate 
between legitimate demands and selfish desires. They 
need to devote much time and careful attention to the 
details of hospital business before vouching for outlays 
and receipts. They should endeavor to secure for the 
patients those attentions and measures which will be 
most conducive to their recovery, physical comfort and 
peace of mind. In this work theyj must have their 
feelings enlisted and their sympathies taxed without 
sacrificing their sense of proportion. Personal inclina- 
tions must at all times be held subservient to public 
expediency. 

If a well-ordered, smoothly conducted, successful 
hospital is the ambition of a trustee board, it must 
secure an able executive head and endow him with 
well-nigh autocratic powers, although the board would 
be blame-worthy if it failed to keep informed as to 
the guiding principles enforced, the general results of 
their application and all important hospital episodes. 
Different boards will obtain the facts pertaining to 
such matters through various methods; the manner 
of acquiring this information is largely determined by 



24 CARE OF THE INSANE 

habit, hospital tradition, the personality of the board 
members and the superintendent. Often the most 
active member of the board, usually the president, 
entertains a lively interest in hospital work and being 
sufficiently free as regards private business, will de- 
vote all the time necessary to his official duties. Thus 
he acquires intimate personal acquaintance with the 
superintendent and the hospital staff and supervises 
in general the actual workings of the hospital regime. 
Naturally he reports to his colleagues a summary of 
what transpires within his cognizance, which practi- 
cally covers the daily round of hospital activities. 
When such a representative trustee is diligent enough 
to include the whole field of hospital operations, is 
sufficiently well informed and well balanced to correctly 
interpret what falls under his observations, and is 
actuated by a high sense of honor and desires to 
promote both individual welfare and public weal, his 
associates show wisdom in following his initiative. 
But a board that blindly or willingly supports a self- 
assertive member who accepts as authentic floating 
gossip and rumors from disgruntled employees and se- 
cret agents, allows carelessness or prejudice more force 
than is consistent with reason. 

The more common and the better way, by which a 
board can keep in practical touch with the internal 



CARE OF THE INSANE 25 

management of the institution it represents, consists 
in dividing hospital operations into departments and 
appointing from its membership special committees to 
oversee, investigate as necessary, and report upon each 
section. By the interchange of information thus in- 
telligently obtained and by free discussions, the entire 
board can keep reasonably well informed upon all essen- 
tial details of routine and even exceptional occurrences. 
It is also good policy for trustees to visit, unattended, 
all parts of an institution. But in so doing it should be 
remembered, especially when making infrequent trips, 
that the underlying motives and the interest displayed 
may be the subject of surmises on the part of many in 
whose interest such tours are planned. 

A trustee should at all times beware of flattery, open 
or veiled, from patients or subordinates. If he enters 
into familiar relations with them, some will take ad- 
vantage of even slight opportunity to ingratiate them- 
selves, and, if possible, injure the standing of others. 
Victims of unwarranted suspicions or pure delusions 
will often endeavor to establish such a sympathetic 
understanding with a trustee that they may transplant 
into the official mind their own prejudiced opinions 
and warped judgment. With the kindest intentions, 
an incautious trustee may accidentally encourage the 
foolishness of some well-meaning person, who, unable 



26 CARE OF THE INSANE 

to comprehend more than one-half the truth or one 
side of an issue, is honestly mistaken, and therefore the 
more insistent upon securing absurd official action. 
Not infrequently malicious falsehoods will be narrated 
with such assurance and circumstantiality that unless 
the occasional ward visitor is exceptionally discreet and 
diplomatic in his comments he may feel some degree of 
humiliation when the facts and the actual situation 
are finally forced upon his understanding. Whether 
investigating for a special purpose or acting upon indi- 
vidual responsibility, a trustee should never decline to 
hear a complaint. Yet ordinary prudence should lead 
him to suspend judgment and to insist that every charge 
of neglect or misconduct be reduced to writing and be 
properly signed by the author of the complaint. H In 
all institutions rumors, especially those interesting or 
startling, circulate with surprising rapidity among both 
inmates and employees, therefore trustees should con- 
stantly guard their speech lest they may thoughtlessly 
answer or comment in terms which patients can quote 
to the injury of others, especially to the subordinate 
officials. And yet trustees should give the hospital 
population ample opportunity to voice their response 
to the discipline enforced — their dissatisfactions and 
their alleged grievances. Then the whole mass of infor- 
mation and misinformation — truth and fabrication — 



CARE OF THE INSANE 27 

should be submitted to the superintendent to be sifted 
and explained as fully as possible. In no other way 
can trustees obtain a comprehensive knowledge of the 
conditions with which a superintendent has to contend 
and thoroughly qualify themselves for intelligent con- 
ferences and helpful suggestions. Besides, they may 
through such thorough canvassing of patients' wards 
learn things of weighty or serious import which had 
not come to the superintendent's knowledge, since it is 
not unusual for patients to persistently withhold from 
him material facts and helpful intimations which they 
will voluntarily report to trustees upon .the first op- 
portunity. Trustees should not be surprised when a 
superintendent confesses inability, without personal in- 
vestigation, to controvert some plausible charge or un- 
ravel some amazing story communicated by a patient. 
The patient may have cunningly omitted essential de- 
tails by which his peculiar view of things could be 
easily recognized. To ascertain from some patients, 
representing certain forms of mental disorder, the key 
which will decipher their garbled or counterfeit state- 
ments requires the skill which comes only from long 
experience with the insane. Then, a superintendent can- 
not be omnipresent, and cannot, because of the limited 
time at his command, keep intimately informed of all 
that transpires within his jurisdiction. However vigi- 



28 CARE OF THE INSANE 

lant himself, he must trust his staff assistants with 
considerable independent authority and depend upon 
their honor and judgment for the variety and minute- 
ness of their detailed reports. Unfortunately ready ex- 
planations from executive officers, who may have been 
suddenly called upon to correct ugly rumors, or clear 
up incriminating statements, should not be accepted 
by trustees as satisfactory and final under all circum- 
stances. Especially is caution in this respect neces- 
sary when by the proffered answer the veracity of some 
other person is impeached or when the trustees burden 
themselves with serious and unnecessary responsibility 
through over confidence in a subordinate. Circum- 
stances can be imagined under which it would be ad- 
visable for them to assume that a superintendent even, 
when interrogated closely, might offer misleading an- 
swers or fictitious excuses, designing thereby to pre- 
serve false pride or conceal inexcusable ignorance and 
personal neglect of duty. Of course this is a mere 
possibility, but that trustees will occasionally differ 
with a superintendent is a probability. Opinions may 
honestly differ as opposite convictions upon many 
questions in dispute logically follow observations made 
from different viewpoints. Each party to a contro- 
versy should therefore in simple justice make certain 
his judgment does not rest upon a narrow, prejudiced 



CARE OF THE INSANE 29 

basis. Then, it is well to bear in mind that the spirit 
engendered in most quarrels, rather than the facts in- 
volved, perpetuates uncompromising conflicts of opinion. 
In any case of serious clashing, however originating, 
the board has the major share of responsibility, as it 
holds the vantage by virtue of its legal authority and 
official rank. It can therefore determine how a solu- 
tion of the difficulties shall be effected. It can act 
summarily and defy consequences, yet it had best be 
conciliatory and first exhaust more gentle methods. 
Without sacrificing authority or dignity, it can in a 
friendly spirit dispassionately review with the superin- 
tendent the points at issue and their development. If 
unsuccessful in reestablishing working relations with 
him, a board will by resorting to benignant treatment 
secure credit for a moral victory and merit the support 
of public opinion. When trustees cease to respect a 
superintendent their official relations should terminate 
for the good of the cause, which cause may be regarded 
as a grand commission for unselfish devotion to afflicted 
fellow men. 

Eleemosynary institutions are monuments indicat- 
ing the degree and strength of philanthropic sentiments 
in a community — not memorials dedicated to past 
achievements, but energetic centers where compassion 
for misfortune and suffering is practically demon- 



30 CARE OF THE INSANE 

strated through the agency of scientific skill, deeds of 
mercy and the arts of genuine sympathy. Hospital 
trustees should cherish the signal honor which is con- 
ferred upon them through their official position, and 
not only plan and vote in accordance therewith, but 
endeavor to impress their subordinates, by example and 
precept, with a constant sense of deep obligation to the 
helpless patients — God's unfortunate children in a spe- 
cial sense — for whose sole benefit such benevolent in- 
stitutions are founded and maintained. 

So far as possible, trustees should agree upon all 
important questions of hospital management. Dissen- 
sions in a board, if serious and prolonged, can scarcely 
fail to reduce the efficiency of the hospital. As a conse- 
quence of board friction executive officers will imbibe 
the virus of uncertainty and may gravitate into oppos- 
ing cliques, while employees will presume upon relaxed 
discipline and the baneful results will have to be endured 
by the innocent patients. When trustees view their 
official duties in the light of a solemn trust for the 
uplift of afflicted humanity, there would seem to be 
little opportunity for personal differences concerning 
the means to be employed. Experience with a model 
board in this respect has demonstrated the possibility 
of practical harmony in hospital work. Under wise 
leadership, minority objections to any proposition were 



CARE OF THE INSANE 3 1 

treated with entire respect, and final action deferred 
while each member endeavored to reexamine his con- 
victions from the viewpoint advanced by others. That 
self-respect which accords such marked consideration 
for the opinions of an associate has an inherent power 
that will force a spirit of humility and a burden of 
self-conviction upon any manly opponent if he is not 
certain of his position, and insure the ultimate adop- 
tion of his views by the majority if he is absolutely 
right. 

When a trustee board adopts a standard of high 
ideals and secures a competent, ambitious superinten- 
dent, excellent results should follow. But a board 
must utilize its opportunities with skill and use its 
power with masterful restraint, if it would fully dis- 
charge its special obligations to the public as well as to 
the state wards. Having established with the super- 
intendent a mutual understanding concerning the set- 
tled policy and the general plans to be pursued, the 
boardl should delegate to him adequate authority to 
enforce his orders and maintain a position of dignity. 
Only under exceptional circumstances should a board, 
acting as a committee of the whole or through its pre- 
siding officer, assume direction in executive affairs. 
The superintendent must be the acknowledged com- 
mander, free to select his working force, to formulate 



32 CARE OF THE INSANE 

details of operation, and to establish his own system of 
discipline. 

Finally, after their hospital has been put in working 
order, the board can render the most effective service 
by occupying the position of rear guard. As trustee 
officials they cannot escape the position of buffer be- 
tween the hospital management and the general public. 
Therefore it becomes their duty, as well as their privi- 
lege, to aid the formation and growth of a public senti- 
ment favorable to the hospital. This they can do by 
cheerfully answering all pertinent questions; by cor- 
recting unfounded rumors; by disarming hostile criti- 
cism, and by freely and fairly discussing with any 
interested person the qualifications, the aims and the 
ambitions of the resident officials. 



SUPERINTENDENTS. 

The responsibility of hospital trustees assumes its 
maximum proportions when the board essays to select 
a medical superintendent, as successful hospital admin- 
istration depends almost wholly upon the individual 
chosen for that office. The attainments and character 
of the chief executive, his medical qualifications, his 
business instincts, his executive capacity and his per- 
sonality have each an important value in fitting him 
for the varied duties inseparable from the position. 
Should the candidate possess acknowledged, even con- 
spicuous, ability in any particular field, medical, com- 
mercial or sociological, such preeminence does not sig- 
nify that he possesses the ability to organize hospital 
work successfully and maintain proper discipline. It 
is a much safer policy to fill the position, with its various 
lines of duty, by appointing an evenly balanced, "all- 
round" man, who in addition to the requisite medical 
knowledge and business capability is blessed with 
abundant common sense, quick perception, a ready judg- 
ment and a passion for justice; for not only must a 
superintendent see that the patients receive the best 

33 



34 CARE OF THE INSANE 

medical care, that hospital funds are prudently han- 
dled, that employees conduct themselves properly, but 
in him should reside these finer qualities of mind and 
heart, — patience, sympathy, courage, enthusiasm, etc., 
— since such attributes of higher manhood must char- 
acterize his administration in order that his life and 
official influence may tone and energize the interrela- 
tions of the whole hospital community. 

It has been the custom to a considerable extent, in 
hospitals for the insane, to promote assistant physi- 
cians whenever the position of superintendent became 
vacant. But the exceptions to this rule have been 
frequent, and the medical chief has sometimes been 
selected from the class of general practitioners of medi- 
cine. In former times, when there was an actual dearth 
of specially instructed, promising candidates for such 
positions, selection from the non-specialist field was 
almost a necessity, and, as a matter of fact, some medi- 
cal superintendents who entered upon their hospital 
duties without previous special experience in the treat- 
ment or management of the insane made a good record. 
In recent years, however, the number of ambitious 
young medical men possessing hospital experience and 
a knowledge of psychiatry has largely increased, owing 
to the fact that the number and size of hospitals for 
the insane have rapidly increased, necessitating a much 



CARE OF THE INSANE 35 

larger staff of assistant physicians and graduate " in- 
ternes" to perform the increased professional labors 
which new views of this work and improved methods 
demand. Therefore, when a reasonable degree of dis- 
crimination is exercised in filling the minor staff posi- 
tions, the promotion of assistants to fill higher vacan- 
cies would seem logical and fitting, especially in those 
institutions where the established lines of management 
are satisfactory to the trustees and all supervising offi- 
cials. Certainly an assistant physician, who after years 
of faithful, continuous service in the hospital has be- 
come familiar with the routine work and the capacity 
of the various heads of departments, upon whose intelli- 
gence and integrity much depends, ought to receive 
the first consideration as a candidate for an advanced 
position. When a superintendent is selected from the 
staff there follows little occasion for suspense on the 
part of the working force, whereas when a hospital is 
placed in charge of an outside man, considerable time is 
usually required for the readjustments which naturally 
follow. Besides, when it is the rule of an institution 
that worthy assistants, if qualified, will be promoted as 
vacancies occur, ambitious men will the more readily 
turn to this line of work. They will regard such prom- 
ises for the future as strong inducement to enter the 
service, and, once engaged, they will work the more 



36 CARE OF THE INSANE 

diligently to perfect their knowledge and fit themselves 
for the duties of the advanced positions. 

While it is a practical impossibility for a superin- 
tendent to become an expert in all departments of 
medicine, he should be well grounded in the general 
science of medicine and have special interest in all that 
pertains to nervous and mental disorders. In large 
hospitals the assistant physicians will necessarily have 
to take charge of details in the clinical, psychiatric and 
pathological work. But the superintendent is often 
obliged to express opinions and make decisions on med- 
ical questions of a wide range, and he has to accept, 
by virtue of his position, the responsibility attending 
whatever measures, medical, hygienic and disciplinary, 
that anyone introduces under his management. He 
must therefore inform himself concerning the essential 
contents of a wide range of medical literature, and inter- 
est himself in all that affects the preceptions and judg- 
ment of those physicians engaged in treating mental 
disorders. If especially interested in scientific medi- 
cine and appreciative of the superior opportunities for 
research work afforded by the large aggregation of 
permanent patients always found in hospitals for the 
insane, he will not rest content unless competent 
workers on his staff are engaged in laboratory studies, 
searching for the origin of, and the cause for, disease, as 



CARE OF THE INSANE 37 

well as deciding the multitude of clinical conditions 
which arise in the wards. Although the superintendent 
may be unable to devote sufficient time to any one line 
of scientific work to master details and dictate the 
measures to be adopted, still all department workers 
should be subordinate to his authority in respect to 
appointments to the positions, the general scheme of 
investigations to be made, and in all matters related to 
discipline. Without such a superintendent, command- 
ing the whole hospital organization, whose authority is 
recognized and respected by all, harmony of depart- 
ment labors and interests cannot be secured and a 
systematic development of the institution work cannot 
be expected. 

For the same reason, it is not advisable to place the 
general business affairs of the hospital under the con- 
trol of a steward or manager acting independently 
of the superintendent's authority. True, the medical 
head of the modern large hospital for the insane, if 
attentive to medical matters, hospital discipline and 
the personal welfare of the patients, cannot be expected 
to note with minute oversight the daily financial trans- 
actions of the institution. He cannot keep himself 
posted upon market fluctuations and perfect his judg- 
ment regarding the quality and intrinsic value of food- 
stuffs, fabrics and other commodities, which are being 



38 CARE OF THE INSANE 

replenished constantly and in wholesale quantities. But 
he should, as a matter of duty, interest himself at 
times in the quantity and quality of supplies pur- 
chased, see that the purchasing agent proportions his 
current expenses to the yearly financial resources, and 
be ready at all times to counsel the official buyer and, 
when necessary, to assume responsibility for any im- 
portant business transactions. When the superinten- 
dent is the recognized chief over all hospital depart- 
ments, he can, as he deems fitting, delegate to a steward 
all the latitude and authority necessary for his semi- 
independent business activities, and be able at the same 
time, upon occasion or necessity, to supplant his passive 
attitude towards the purchasing agent with positive 
vetoes and commands. And this he can do without 
scruple or risk of friction, when the business depart- 
ment is officially subordinate to the superintendent. 
It must be admitted that hospital affairs have been 
successfully conducted under the divided executive 
system and apparently without developing jealousies. 
But such happy issues under the vexatious dual system 
are exceptional and depend upon the fortunate per- 
sonality of both the medical and the lay director, who 
usually attempt to administer the affairs of a hospital 
unit thus organized not conjointly but working inde- 
pendently of each other; each controlling separate sec- 



CARE OF THE INSANE 39 

tions where cleavage is imperfect and duties tend to 
overlap, where individual interests are certain to con- 
flict, and where arbitrary trustee rules become necessary 
to establish the bounds of each man's province. 

When asylums for the insane were first established in 
this country, the then prevalent English system of man- 
agement was adopted. A resident physician or medi- 
cal superintendent was appointed to treat and manage 
the patients; but a lay superintendent, or steward, 
was quartered upon the premises and all business 
affairs were conducted under his independent authority. 
Among the other duties of this non-medical head was 
the employment and official discharge of attendants 
and nurses. Under that form of management, in those 
days, it was generally understood that an irritating 
degree of hospital discord was the result. The medical 
head chafed under a sense of injured dignity, finding 
his plans frequently obstructed and the scope of his 
ambitious ideals restricted in ways that provoked re- 
sentment and effectually humiliated many worthy but 
sensitive medical superintendents. When, as was the 
usual case, the trustees maintained more intimate rela- 
tions with the business than with the medical head, the 
professional man had no recourse and perforce exhausted 
much of his power for better things in suppressing sour 
complaints and imagining the happy outcome possible 



40 CARE OF THE INSANE 

under more agreeable and more favorable conditions 
of management. If there ever existed any substantial 
reason for the adoption of such schemes of hospital 
control, calculated chiefly to discredit the executive 
and business ability of the professional official, its valid- 
ity was never admitted by medical men. In recent 
times, public opinion on this question has changed so 
radically that nearly all large hospitals, those treating 
general diseases as well as the special institutions, are 
now placed in charge of superintendents possessing a 
medical education and a doctor's degree. When such 
a superintendent in a general or special hospital is 
assigned no active medical duties, still his medical 
training is regarded as an essential qualification for the 
position, as it alone enables him to clearly comprehend 
the aims and objects of the organization as a whole 
and to harmonize the interests and adjust the activi- 
ties of the several departments. His technical knowl- 
edge tends to eliminate friction, as it inclines him to 
cooperate with the staff physicians and enables him to 
recognize the necessity of numerous but important 
accessories which are requisite to perfect the hospital 
equipment. 

But the education, medical and general, possessed by 
a hospital superintendent is of little avail unless he is 
gifted with native talent for executive work. Genuine 



CARE OF THE INSANE 41 

executive ability can scarcely be acquired, although the 
cultivation of natural aptitude increases its efficiency. 
It is the inborn faculty of recognizing things in their 
correct relation to each other; of seeing at a glance 
where and when to initiate action which will naturally 
produce desired results. It is that variety of ability 
which enables some men to utilize advantageously the 
combined services of others in working out the details 
of broad plans. It is an instinctive capacity to appre- 
hend causes, to marshal events, and to select competent 
men for each post of duty, and depends upon a fertile 
imagination controlled by logical mental processes. 

A superintendent should possess quick and accurate 
perceptions so he can acquire and assimilate informa- 
tion rapidly. He should employ his time to advantage, 
and, to cover the whole field of his interest, he should 
be able to note mentally the chief or accidental details 
of whatever requires even his momentary attention. 
He must be able to store his mind with a large fund of 
knowledge and comprehend practical results without 
adopting the slow process of asking questions. Com- 
mendable business prudence on his part should be self- 
evident in his reports to trustees and his everyday 
intercourse with those who have business relations with 
the hospital. 

To command respect, a superintendent must be a 



42 CARE OF THE INSANE 

wise disciplinarian. The glory of a large hospital or- 
ganization depends upon its machinelike action in pro- 
ducing results of a high order. Human beings in a 
mass, each with individual opinions and interests, are 
brought into active association for a common purpose. 
Officers of various ranks, several grades of employees 
and a large community of irresponsible patients must 
here adjust their several relations, each with others; 
living in concord and working in harmony for purposes 
which the superintendent formulates. Orders emanat- 
ing from this supreme official should stimulate and regu- 
late activities at every post and in all grades of the 
organization. If the working of the system appears to 
be automatic, if only the regularity and smoothness of 
the daily movements attract attention, and if happy 
results only are realized, then it may be safely assumed 
that the person in command is a good executive and a 
thorough disciplinarian; firm, judicious, and consistent 
in exercising his authority. In this sphere of duty the 
superintendent must assert his sovereignty, command 
obedience, reprove inefficiency, reward the faithful, and 
trust his own judgment. Circumstances often compel 
him to delegate more or less power to subordinates, yet 
he will have to accept responsibility for all orders and 
decisions thus given in his name. It is therefore very 
important, considering his interests and reputation as 



CARE OF THE INSANE 43 

well as the comfort and satisfaction of his staff, that all 
who come into official contact with him should clearly 
understand his views, his methods of reasoning and his 
theories concerning rewards and penalties. Members 
of his staff should be able to predict how he would act 
in case any given hospital rule were violated. This is 
possible only when his system of discipline is based upon 
well-established principles, consistently interpreted. In 
his conduct towards others, officials, employees and pa- 
tients, he should aim to be just. Then let his process 
of discrimination be accurate and he will soon establish 
in the minds of his associates a reputation for righteous 
dealings which everyone can comprehend and his sub- 
ordinates may copy. All men respect him whose acts 
bear the hall mark of rectitude, and have no difficulty 
in deciding what attitude such a person would take 
under any known circumstances. If a superintendent 
allows personal timidity, favoritism or prejudice to 
warp his judgment, if he temporizes with offenders 
because of their threats to seek revenge or because 
inconvenience to the management will result if such are 
discharged, if two employees commit like misdemeanors 
and one is discharged while the other is retained in 
service because of his musical or ball-playing ability, 
confusion will follow. Subordinates in the hospital 
will thereafter evade questions of discipline, ignore 



44 CARE OF THE INSANE' 

minor faults, and defer judgment in more serious cases. 
As nothing more quickly vitiates discipline than dis- 
charging employees unjustly, the superintendent should 
make certain that he fully comprehends the situation 
before extreme action is taken. It is especially fortu- 
nate if one, in a responsible position, has the capacity 
for correctly and promptly reading human nature, as 
it greatly aids in reaching conclusions regarding per- 
sonal reliability and merit. Occasionally it may be 
expedient to make an exception to an established rule, 
but the neglect or abuse of a patient should never be 
overlooked or excused. The superintendent's respon- 
sibility for the custody and proper treatment of large 
numbers of defenseless patients under exposed condi- 
tions admits of no deviation from the rule. 

In managing patients some show of discipline must 
h$ observed, but rigid and severe measures should never 
he adopted, except as a last resort, after mild methods 
have been found unavailing. Under all circumstances, 
mildness, consideration and mercy should characterize 
the enforcement of discipline with insane patients. It 
should be remembered that if they were legally respon- 
sible they would be elsewhere. If such persons retain 
moral responsibility of any degree, it is wise to culti- 
vate what exists rather than submerge it in feelings of 
bitter resentment. The superintendent's relations with 



CARE OF THE INSANE 45 

his patients include that of "in loco parentis." His 
established reputation for high ideals of manliness and 
justice is the only guarantee which the public can de- 
pend upon that the inmates of hospitals for the insane 
will be kindly and properly treated. They are in his 
keeping. They class legally as children, and it is his 
solemn duty to protect them in those privileges and 
rights which the state especially bestows through their 
commitment to his care. Thus are their legal rights 
established, and all should recognize that their moral 
rights are vastly increased because of their helplessness 
and the legal restrictions to which they are subjected. 
As regards personal conduct in hospitals for the insane, 
the superintendent is lawgiver, judge, jury and sheriff. 
But, above all, he should be the guardian of, and advo- 
cate for, the patients. Let justice requite the faults 
of the patients as well as those of the employees; but, 
in the case of the patients, let it not be a blindfolded 
dispenser of law, such as is suggested by the conven- 
tional, emblematic statue of Justice, but rather a clear, 
open-eyed apostle of recompense, who, through humane, 
compassionate sentiments, recognizes that their calam- 
itous mental condition totally changes the nature and 
degree of individual responsibility in the case of the 
insane. 
Unless a superintendent's attitude towards his pa- 



46 CARE OF THE INSANE 

tients is inspired by a warm heart, and unless his in- 
terest in their condition and needs is tinctured with 
spontaneous sympathy, his power for good in his own 
institution will be seriously restricted. But his sym- 
pathies must be of the rational, intelligent order that 
color and soften his judgments and commands; not 
the blind, hysterical sort that will sacrifice an ultimate 
good for temporary emotional satisfaction. Occasions 
will arise, no doubt, when the sympathetic inclination 
must be overruled, but usually it will suggest the better 
policy, produce most comfort and the best results. In 
state hospitals there will always be a large class of 
inmates who require little if any medical treatment, 
but whose mental distress and sense of loneliness can 
be largely effaced through the agency of sympathetic, 
moral treatment. And such treatment must be adopted 
and persistently practiced by those who endeavor to 
avoid the employment of mechanical restraint. The 
spirit of the man in authority can but affect each person 
within the circle of his rule, and therefore, if a super- 
intendent is possessed of large sympathies and has the 
courage to exercise them, he cannot fail to soften the 
views of his subordinates and thus aid all who depend 
upon him. He must have the courage to give and the 
courage to withhold as circumstances appeal to his 
judgment. But in all his dealings with subordinates 



CARE OF THE INSANE 47 

and patients he should be positive. He should have 
well-grounded convictions and the courage to shape in 
accordance therewith his own life and their line of duty. 
He should cherish high ideals and expend energy in 
striving to reach his adopted goal. His success will 
largely depend upon his native fortitude. If he at- 
tempts to cross the channels of institutional habits, 
however unwisely established and blindly followed, or 
if he proceeds to substitute the " non-restraint" system 
for the long-used strait-jacket and isolation cell, there 
will be serious obstacles to overthrow, plausible argu- 
ments to refute, and institutional inertia to remedy and 
energize. 

If accidents occur under the workings of new methods 
which he had adopted upon convictions as to their 
beneficial results, he should be resolute enough to de- 
fend his working principles. Let him modify and per- 
fect his details, if necessary, but defend a system which 
he knows to be correct and work with ripened experi- 
ence and renewed faith. The long-delayed reform in 
the treatment of the insane is explained by the lack of 
courage on the part of the old-time custodians. They 
feared to act contrary to tradition, and saw no reason 
why they should voluntarily assume burdens of respon- 
sibility for the sake of helpless and friendless insane 
persons. Public opinion, intrenched in old supersti- 



48 CARE OF THE INSANE 

tions and trammeled by fear and timidity in respect to 
mental disorders, approved the most galling methods 
of restraint. Security, not restoration, seems to have 
been the only object for which the insane were seques- 
tered and the only motive which consigned mental 
invalids to lives of horror within prison dungeons. 
When no one questioned the propriety of tying the 
hands and feet of an insane man, strapping him firmly 
to beds and chairs, or chaining him securely to the 
wall, custodians conceived of no reason why inmates 
under their watch and care should be permitted to 
destroy clothing or get an opportunity for escape or 
suicide. Public sentiment was unenlightened with re- 
spect to the necessity for this condition of affairs, and 
the feelings even of religious people towards the in- 
sane were hostile. What the insane have suffered 
through the absence of sympathy and courage on the 
part of those whose duty it was to protect, cherish and 
cure them, we cannot adequately realize. May the 
future, by humane and kindly methods of treating the 
insane, atone in some measure for past neglect and 
wrong! Tuke was sympathetic and courageous when 
he took the Quaker insane out of the government asy- 
lums and treated them in the York Retreat like sick, 
inoffensive children. Pinel exhibited heroic courage 
when he removed from the insane in Salpetriere the 



CARE OF THE INSANE 49 

irons and chains which they had worn for years, espe- 
cially when in doing so he had to defy official protests 
and ignore universal predictions of resulting confusion, 
accidents and even homicides. 

Medical officers in all hospitals for the insane fre- 
quently come into relation with cases calling for coura- 
geous action. Within comparatively recent years a male 
patient was released from an isolation-room in a New 
England hospital after he had been kept in seclusion 
about thirty years because of his hostile demonstrations 
and repeated acts of ferocity. Prior to his attack of 
mental disease he was a prominent lawyer, and he firmly 
believed his confinement was illegal. In the presence 
of hospital officials, attendants and visitors he always 
protested against the fancied injustice of being kept 
with the insane. By way of expressing his vehement 
objections to hospital imprisonment, he spent hours 
daily kicking the heavy oaken door which prevented 
his egress. So long-continued and so vigorous had been 
this habit that considerable deformity of both feet had 
resulted. Finally a resolute assistant physician termi- 
nated the isolation of this long-feared maniac and he 
was permitted to mingle freely with other patients in 
the general ward and upon the hospital lawn. He injured 
no one, and within two months could have been seen en- 
gaged in ball playing with other patients on the grounds. 



50 CARE OF THE INSANE 

At a still more recent date and in another New Eng- 
land hospital a young medical officer who possessed the 
courage to act upon his convictions removed from the 
wrists of a patient manacles which had been worn for 
many years, because the other hospital officials had mis- 
judged the patient's mental attitude and magnified his 
capacity for vicious conduct. The irons had been worn 
so long that rust prevented their removal by the use of 
a key, and the arts of the blacksmith were required to 
unshackle the man. During his subsequent hospital 
history this patient gave no trouble whatever. 

Every superintendent who has inaugurated radical 
improvements in the management of the insane has 
been proclaimed a fanatic by timid officials and criti- 
cal onlookers, until practical success demonstrated the 
wisdom of his innovations. To-day, while politicians 
and the public press assume to work for the benefit of 
the inmates of hospitals, their narrow views of hospi- 
tal methods and their hasty, ill-considered criticisms of 
hospital management through inordinate desires to gain 
sensational notoriety actually increase restrictions upon 
the insane, since they often overawe and intimidate 
superintendents who desire to extend more freedom and 
parole to insane patients in hospitals. 

It is good fortune for all concerned, both officials and 
patients, if a medical superintendent is possessed of a 



CARE OF THE INSANE 5 1 

sanguine temperament and is dominated mentally by 
optimism — not the fanatic sort, but a spontaneous spirit 
of hopefulness which conforms to practical experience 
and is regulated by common sense. Often his line of 
duty and progress will be blocked by obstacles formi- 
dable enough to thwart his best intentions unless he 
is gifted with an overmastering tendency to prefigure 
mentally the blessings and benefits certain to follow 
perseverance in the course he had carefully mapped out. 
If he have faith in his own judgment and confidence in 
his ability to attain success, he will overcome all oppo- 
sition by persistent struggles. When the opposition is 
too strongly intrenched for direct attack, he will devise 
a flank movement and succeed through skillful man- 
euvers. Optimism dissolves doubt, countervails timid 
advice, lifts one above the commonplace grooves of rou- 
tine, and favorably modifies the force of traditional 
authority. When it characterizes a superintendent's 
official relations with his medical staff and lay workers, 
their mental horizon expands and their desire for a use- 
ful career takes on fresh vitality because of the expectant 
possibilities before them which his optimistic interpre- 
tation points out. It is the basis of that enthusiasm 
which is essential to the most successful leadership. 
The wise master avoids the arbitrary tactics of the boss, 
but stimulates the aims and energies of his subordinates 



52 CARE OF THE INSANE 

through persistent and consistent presentations of the 
brilliant prospects ahead which invite their ambitious 
pursuit. When hospital officials and employees actually 
read into their daily toil new meanings freighted with 
promise and illumined with elevating sentiments, their 
capacity for labor becomes augmented and weariness 
from effort is almost abolished. 

Patients who fall under such salutary influences are 
taught to cultivate expectation, and to foster the bright- 
est prospects that are reasonably within their grasp. 
By this process of sympathetic encouragement, some 
will recover hope and develop a faith which will aid, 
if not engender, the process of recovery. Many cases, 
chronic and hopeless as regards mental restoration, may 
thus become imbued with the buoyant spirit and pos- 
sibly find comfort in the reflection that their condition 
might possibly have been worse than it actually is. 
Thus the superintendent's feelings and spirit are diffused 
through the whole hospital group and his optimistic out- 
look may glow in the faces and mark the speech of both 
officers and patients, to such a degree that even casual 
visitors may note the prevalent tone of good cheer and 
hope and therein discern the keynote of the hospital ad- 
ministration. A pessimistic physician is out of place as 
the head of a hospital for the insane. His constitutional 
tendency to look for and dwell upon the facts and cir- 



CARE OF THE INSANE 53 

cumstances of a disquieting character which are strik- 
ingly obvious in most cases of insanity, intensify the 
morbid propensity of despondent patients to indulge 
ideas and reflections which are most painful and which 
prevent or retard a possible recovery. Then the over- 
shadowing, myopic philosophy expressed in the phrase, 
" What's the good? " smothers the happier and stimu- 
lating sentiments which alone render bearable the hos- 
pital existence of the average chronic patient. Under 
such gloomy supervision the ambitions of assistants are 
checked and employees view their obligations to patients 
in a perfunctory way. In all enterprises where social 
questions and human sentiments are involved, the cyni- 
cal, pessimistic man is a foredoomed and pestilential 
failure. 

Finally, the act of resigning his position before the in- 
firmities incident to advancing age impair his executive 
abilities is a supreme test of a superintendent's wisdom. 
When he has accomplished his immediate aim and done 
institutional work which has favorably impressed the 
medical profession and the general public, he will be 
strongly tempted to remain in the service too long, 
living upon his well-earned reputation, and will un- 
consciously fall into routine operations because his 
potential capacity for initiative has passed its meridian. 
Under such conditions, he can add nothing to his fame 



54 CARE OF THE INSANE 

and may impede progress which younger men, stand- 
ing perhaps upon foundations which he had earlier 
established, will have the foresight and energy to 
inaugurate. When a man's lifework has received due 
acknowledgment from those who understand the situa- 
tion and whose judgment is valued, he may retire 
satisfied; and, calling to mind the fact that one can- 
not expect to be a personal power for leadership 
except with his immediate contemporaries, he should 
willingly step aside and open an opportunity for new 
men with fresh energy and ambitious aims. His ex- 
ample, his fame, his high purposes and good works are 
more inspiring to others than would be his continued 
efforts, through subsequent years of declining physical 
and mental vigor. Continual progress is the natural 
order of events in social and scientific affairs, and the 
man who has concentrated his attention, year after year, 
upon certain lines of advance has probably magnified 
his objective points until they are out of correct propor- 
tion as he sees them. It is eminently fitting, therefore, 
that medical superintendents with a record of long ser- 
vice, especially those who have been devoted to the ad- 
vancement of certain features of management and have 
in fair measure realized their ideals, should, before cir- 
cumstances compel abdication, vacate the positions with 
which they have been identified, and permit successors 



CARE OF THE INSANE 55 

to enter the field of operations. The broad, open- 
minded ex-superintendent should in the end find his 
greatest satisfaction in realizing that his own work will 
be utilized by those who come after him as a stepping 
stone to still higher achievements; in cheering on those 
who take up the work where he left off; and in the serene 
conviction that they will establish greatly desired ad- 
vances in medical science and in the treatment of in- 
sanity which he could but fondly anticipate. 



THE MEDICAL STAFF. 

Assistant physicians should be appointed, or pro- 
moted, only upon the recommendation of the superin- 
tendent. For interested trustees or practical politi- 
cians to force the nomination of a particular candidate 
against the free judgment of the superintendent is sub- 
versive of that discipline which he must maintain if his 
administration is to command respect. In settling pre- 
liminary questions regarding appointments, it is emi- 
nently proper that the superintendent should confer 
with trustees, especially with medical members of the 
board ; but the fact remains that he can best decide as 
to the kind of man required to fill the vacant post and 
best judge of the candidates' capabilities, notably so 
in cases of promotion. 

In selecting assistants, great care should be exercised 
to ascertain the facts regarding the applicant's character, 
his habits, his guiding principles and his predominant 
sentiments. A record for brilliant scholarship should 
not of itself be permitted to outweigh established repu- 
tation for sobriety, truthfulness, habits of industry, 
and tenacity of purpose. An assistant physician whose 
word cannot be depended upon is a stumbling block for 

57 



58 CARE OF THE INSANE 

the management and a menace to the good name of the 
hospital. When a superintendent relies upon the word 
of an assistant who is guilty of misrepresentation, most 
painful embarrassments will naturally follow. Patients 
even distrust and condemn untruthful medical assist- 
ants, and the friends of patients resent being imposed 
upon by falsehoods when they have the undoubted 
right to know the facts. Then, the hospital records 
kept by assistants must bear the stamp of honesty, as 
scientific work is impossible when the medical records, 
even to minute details, are not absolutely reliable. 

Young medical men should feel honored when they 
receive a hospital appointment and strive through right 
conduct and honest work to add dignity and impor- 
tance to the position. While occupying subordinate 
posts they should be loyal to their superior officers; 
not because tenure of office may depend upon such 
observances, but for the reason that fidelity is a basic 
principle of true manliness. It is not advisable to en- 
cumber the personal movements of staff officials with 
many inflexible rules and regulations. Assistants who 
cannot be trusted to regulate their general conduct 
according to the code of gentlemen, who cannot treat 
employees with kindness and courtesy without sacri- 
ficing official dignity, and those who on the hospital 
premises, whether on duty or off duty, ignore the social 



CARE OF THE INSANE 59 

distinctions which their official rank confers, ought not 
to be promoted, possibly not even retained in the service. 
Rules outlining duties must be established to system- 
atize the procedure of such community workers. But 
men competent to fill staff positions must have out- 
grown the necessity for petty restrictions. Their plain 
obligations and sense of honor should suffice as ample 
guides for deportment. However, it should not be taken 
for granted that the burden of obligation rests wholly 
upon assistant physicians; that their reasonable claims 
for faithful labors are wholly liquidated by a meager 
salary. 

That they have some moral claims upon the manage- 
ment should be admitted. When they voluntarily sub- 
scribe to the supreme authority of the superintendent 
they must of necessity trust him to pilot them wisely, to 
instruct them in the best methods of hospital manage- 
ment, to facilitate their quest for scientific knowledge, 
and to assist the worthy ambitious in securing promotion 
either under his management or elsewhere as opportu- 
nity may offer. A superintendent who in his relations 
with his assistants rests satisfied upon his opportu- 
nities to pose for admiration, all the more flattering 
if mingled with envy, violates his deeper obligations 
and disregards noblesse oblige inherent in his official 
position. Officially and socially, he should treat them 



6o CARE OF THE INSANE 

with the respect due members of his official family. 
He should encourage them to rise above trivial annoy- 
ances and personal jealousies which too frequently in- 
vade official families in pub He institutions. He should 
make it emphatically plain to their comprehension that 
the first and highest duty of every hospital official 
relates to the care and treatment of the patients, pro- 
tecting them from abuse and promoting their restora- 
tion to health through an exhaustive study of their 
cases, scientific treatment, and the arts of a true phi- 
lanthropist. Young physicians entering upon staff 
duties should be aided to adjust themselves to the re- 
quirements of their new responsibilities. Invested with 
delegated authority from the superintendent, they will 
be required to aid in enforcing discipline, and, where 
" non-restraint" of patients is insisted upon, they must 
feel considerable uncertainty as to what attitude to 
take where perplexing conditions are wholly new and 
their experience is limited. If they are inclined to 
accept the views and conclusions of the superintendent, 
it will require time and numerous observations for them 
to clearly apprehend the principle of " non-restraint," 
the great importance of its enforcement, and the best 
methods of its application to the ordinary and extraor- 
dinary incidents which daily occur in the hospital 
wards. For a time they can do no better than respect 



CARE OF THE INSANE 6 1 

the superintendent's scheme of management, accept his 
suggestions and refer all complicated cases to him for 
solution. When assistants make mistakes, he should 
take the first occasion to analyze the faults, point out 
the errors and explain how satisfactory results would 
have followed wiser action on their part. If a second 
lesson on the same subject becomes necessary, the super- 
intendent should make his instructions sink deeper if 
possible. When circumstances will allow consideration 
to be shown, even a serious mistake, if honestly re- 
gretted by the assistant, may be overlooked; yet it 
should be made plain that a repetition of serious blun- 
ders could not be condoned. 

It is impossible for a superintendent to review all the 
doings of his assistants, but new men should be cau- 
tioned against the too free employment of drug medi- 
cation. Young men fresh from the schools incline to 
prescribe hypnotics to excess, and to use hypodermic 
needles too freely. 

The details of ward work must be left to the assist- 
ants, but the superintendent must retain oversight and 
discharge his obligations to both assistants and patients. 
So far as the professional medical work applies, he can 
best serve both parties by adopting the practice of a 
daily clinic to be conducted each morning by the assist- 
ant physicians under his supervision. In no other way 



62 CARE OF THE INSANE 

can he take time, with his many executive duties, to 
thoroughly satisfy himself that the physical and mental 
state of each patient has been carefully investigated; 
that complete and reliable records of the condition of all 
patients are being promptly made; that the junior mem- 
bers of the staff understand their work and are making 
satisfactory progress in the study of insanity. In short, 
every large hospital for the insane should be converted 
into a specialized medical school for graduate students, 
where clinical and pathological work can be correlated 
and pursued to the best advantage. If, through the 
superintendent or the laboratory director, a close con- 
nection with the teaching force of some not-too-distant 
medical school can be arranged, the association may be 
made one of much advantage to the hospital by attract- 
ing students to the special work of hospitals, stimulating 
members of the staff to produce better results, and by 
giving the hospital a better standing among members of 
the medical profession. 

The superintendent should see that every patient 
entering the hospital becomes in due time the special 
subject of a clinical conference. In large hospitals with 
frequent admissions — as many as five or six hundred 
new cases yearly — this broad system of clinical demon- 
strations has been practiced year after year to the com- 
plete satisfaction of all officials. The simplest method is 



CARE OF THE INSANE 63 

to list in two classes, male and female, all patients ad- 
mitted. The assistant physicians should also be listed 
in two groups, — those who have charge of the male 
and female wards, respectively. Keeping the male and 
female departments separate, the assistants in regular 
rotation should have assigned to their charge the patients 
in the order of their enrollment on the admission books. 
By this arrangement, favoritism, collusion and selfish- 
ness are guarded against and each doctor has a fair and 
equal chance of getting the easy and the interesting 
cases, while choice, or exchange, of cases should not be 
permitted except with the superintendent's approval. 
The assignment of a patient to a particular physician 
under this scheme signifies that he must make the physi- 
cal and mental examinations, ascertain the previous 
history of the patient, and by questions, verbal and 
written, addressed to the patient, his relatives and 
friends, accummulate all possible information that bears 
upon the patient's mental endowment, developmental 
epochs, education, youthful and adult habits, the appar- 
ent cause for the mental disorder, its progress and its 
tendency towards recovery or dementia. All such evi- 
dence, his personal observations, etc., should be dic- 
tated to a stenographer, or recording machine, to be 
typewritten and massed together in the individual case 
portfolio. A careful analysis of the mental condition 



64 CARE OF THE INSANE 

should be given and, when obtainable, enough of the 
patient's conversation, answers to questions, flight of 
ideas, incoherent utterances, etc., should be quoted at 
sufficient length to fully illustrate the patient's mental 
state. The diagnosis, or provisional diagnosis, should 
be stated and a differential diagnosis should be elab- 
orated and recorded. Work of this sort, when done with 
nice discrimination, will add much to the value and in- 
terest of the hospital records; besides, it will rapidly 
develop the examiner's diagnostic sense. Finally, he 
should write out his opinion regarding prognosis. As 
soon as all these details have been considered, decided 
upon and typewritten, the examiner should announce 
his readiness to present the case and arrange with the 
superintendent a date for this purpose. Ordinary cases 
can be properly presented in thirty minutes, and there- 
fore at least two cases should be in readiness for each 
clinic. 

An early morning hour, prior to time for regular ward 
visits, affords the most convenient time for such clinics. 
They start the day's work promptly and in a decid- 
edly stimulating way, and at this early hour the super- 
intendent is less likely to be called away by visitors 
and business engagements. Prompt attendance by the 
whole medical staff should be insisted upon. The super- 
intendent should regard his own attendance upon the 



CARE OF THE INSANE 65 

conference as imperative. He should brook no delay 
but be present at the moment appointed and preside as 
at a formal medical meeting. The assembling place 
should be near the main office. The hospital library 
often proves convenient, but a room with abundant 
sunlight should be selected if practicable. When the 
patients are too excitable or too infirm to be transferred 
from the wards for clinical demonstrations, adjourn- 
ment to the patient's room or bedside can be ordered 
after the case records have been read and the condi- 
tions explained. Before the patient is brought into the 
presence of the staff, the examiner should read his com- 
plete records of the case. Then, producing the indi- 
vidual, if in suitable condition, he should, by questions, 
explanations, and by the aid of various tests, demon- 
strate the existing evidence of mental disorder in the 
case, call attention to nervous conditions, specify indi- 
cations of physical defects or injuries, and point out 
the special features of the case which he had described 
in the history and explanations previously read. It 
should be his aim to convince all present that he had 
properly canvassed the case, skillfully grouped the salient 
symptoms and correctly interpreted their significance. 
Then the other assistants present should be at liberty 
to examine the patient, ask questions, expose addi- 
tional or obscure symptoms if detected. When all pres- 



66 CARE OF THE INSANE 

ent have availed themselves of reasonable opportu- 
nities in this respect, the patient should be dismissed 
and returned to his ward or room. As soon as the 
patient leaves, the superintendent, or the temporary 
chairman, should call upon each physician in turn to 
express his opinion of the case. If anyone thinks he 
has observed sufficient evidence to warrant the venture, 
he will probably regroup the distinctive symptoms and 
contend for a diagnosis different from that advanced 
by the original examiner. Such discussions become es- 
pecially interesting and instructive when arguments are 
supported by quotations from recognized authorities. 
The substance of all remarks made in the clinical dis- 
cussion should be recorded at the time in a special 
journal kept by the staff, each member in turn serving 
for one month as secretary, unless a stenographer can 
be employed for this service. When the condition of 
the patient subsequently undergoes a marked change, 
the case should be again presented at a staff clinic, and 
all patients should be thus carefully examined immedi- 
ately before their discharge. At such final appearance 
before the staff a statement covering each patient's hos- 
pital experience should be elicited and complaints or 
fancied grievances should be fully recorded. This staff- 
meeting record will become more and more interesting 
as time lapses and will be consulted surprisingly often as 



CARE OF THE INSANE 67 

a case progresses ; is discharged, is readmitted, or termi- 
nates by death. All the clinical and staff-meeting rec- 
ords should be rendered available for special study by 
a suitable card index carefully kept. 1 One hour a day 
spent in such staff-meeting clinics will enable the super- 
intendent to obtain full information concerning the 
patients under his care, to make certain that none is 
overlooked in respect to such critical examinations, and 
that the assistant physicians are diligent and thorough 
in their professional work. The fact that many of the 
cases thus written up and discussed will eventually be 
found in the autopsy room, where the pathological con- 
ditions can be definitely determined, when and where 
the opinions recorded on the case sheets and in the staff- 
meeting journal can be confirmed or refuted, spurs on 
each physician to do his best work, and continuous work 
of such a character perfects his medical education. 

The fact that a physician examines, watches over and 
reports a case does not necessarily consign that case to 
wards over which he presides. The condition of the 
case will probably determine its classification and ward 
location, and all patients in a given ward should be 
managed and prescribed for by the assistant in charge 
of that division. New cases as a rule go into the 
reception wards, and consequently all the assistants 
1 See Card Index in Appendix. 



68 CARE OF THE INSANE 

will have patients under special observation in the male 
or female admission wards at the same time, as each 
man must follow his cases, at least during the acute 
stage or until he has completed the preliminary case 
records and presented the case at the clinic. This 
system permits every man on the staff to engage in 
studying fresh, acute cases, even when his regular ward 
duties are in sections of the hospital occupied by chronic 
patients. It might be supposed that such a mixed 
arrangement would result in friction between members 
of the staff, but where the scientific spirit is properly 
encouraged jealousies are dispelled and the men work 
side by side in peace and with mutual advantage. 
Although no one can predict in advance whether any 
particular case will eventually be the subject of an 
autopsy, it becomes necessary to prepare the clinical 
records of every case with sufficient care to render 
them available and useful, provided the autopsy ever 
does occur. A searching examination should therefore 
be given every case, and under that practice no case, 
however forlorn or demented, is uninteresting. Nearly all 
the patients are pleased by having their condition, their 
infirmities even, made the subject of serious investiga- 
tion, and the friends of such patients always appreciate 
the special interest shown by critical examinations. 
Junior assistants should commence to take their share 



CARE OF THE INSANE 69 

of assigned cases early in their hospital service, and in- 
ternes, if graduates or advanced medical students, should 
take some cases for practice in making examinations, 
writing histories and conducting clinical demonstra- 
tions. Inexperienced men will for a time require some 
aid and suggestions in this work, but the necessary 
help can always be obtained from the experienced 
senior assistants. 

Staff physicians devoted to laboratory work should 
attend the morning clinics, taking part in the discus- 
sions, and express opinions when called upon ; but unless 
they are anxious to spend time in studying psychi- 
atry they may as well be excused from making case 
examinations and clinical demonstrations. Their spe- 
cial field of work renders it encumbent upon them to 
make the laboratory examinations and findings inter- 
esting and profitable to the clinical assistants. One or 
more evenings each month should be set apart for lab- 
oratory staff meetings, at which the laboratory chief, 
by the aid of microscopes, or, what serves the purpose 
much better, a projection apparatus, should exhibit tis- 
sue changes in the brain and body organs as found 
in recent post-mortem subjects. In connection with 
the display of pathological conditions, let him review the 
clinical records in the cases represented and note the 
erroneous, as well as the correct, diagnoses therein re- 



70 CARE OF THE INSANE 

corded by the clinical workers, and again they are 
reminded of the importance of wide and accurate medi- 
cal knowledge as well as of skill in applying it. When 
the members of the medical staff realize the advantage 
they derive from thorough autopsy work and interest 
themselves in obtaining permission from the relatives 
for such examinations, consent can be secured in more 
than half the deceased cases; and when assistant phy- 
sicians have every reason to expect that at least fifty 
per cent of their patients will eventually be subjected 
to post-mortem and microscopic examinations, that 
any one of the many patients under their care may 
by chance come into the post-mortem class, their 
professional work will be done with the utmost care 
without urging or nagging from the superintendent. 
Requiring such exacting work of assistants will not be 
resented by men of ability and ambition, as they must 
admit that thorough examination and careful treat- 
ment of patients are reasonable demands, and they must 
also realize that the proficiency they acquire by such 
painstaking examinations, critical discussions and clini- 
cal demonstrations becomes a valuable personal asset 
of their professional capital. It invests them with such 
a degree of confidence and self-reliance that they can 
appear with credit before any medical society, present- 
ing cases and taking part in discussions. 



CARE OF THE INSANE 71 

In hospitals where careful professional work is done, 
the physicians' time becomes too valuable to be spent 
in clerical labors. Even internes in all hospitals should 
be spared such time-wasting work as writing case his- 
tories with the pen. Dictating to a stenographer, or 
a recording machine, not only economizes time but 
is time well spent because it rapidly improves one's 
diction. 

Another line of duty usually imposed upon staff 
physicians in well-organized hospitals consists in giving 
lectures to nurses in the training school. This task 
should be welcomed, as the practice more than repays 
the lecturer for all the mental application expended 
upon that work. 

Men engaged in hospital work on a scientific basis 
should be granted liberal vacations. Many of their 
duties are exacting and nervously exhausting, and where 
they faithfully work out their case histories and attend 
routine ward duties they require frequent resting spells. 
Without doubt men can accomplish more first-class 
work within a year, when at least one month is given 
up to change of scene and relaxation from official duty. 

Hospital managers make a mistake if they allow an 
assistant physician of ability and promise, with a satis- 
factory record, to resign when he would remain in the 
service if free to marry and suitable apartments were 



72 CARE OF THE INSANE 

provided for him. The additional expense to an insti- 
tution incurred by caring for married assistants and 
their families is usually a good investment, as it insures 
a contented official and the long-continued services of an 
interested and experienced man. 



HOSPITAL LABORATORIES. 

The laboratory has come to be the vital center of 
hospital work, as it is impossible to practice medicine 
at the present day without employing laboratory meth- 
ods to determine the real basis for many physical dis- 
orders. Pathogenic bacteria are associated with so 
many diseased conditions which call for intelligent 
positive management that apparatus and material for 
bacteriological cultures, stains, and identifications must 
be conveniently accessible on the premises unless a 
public board-of-health laboratory be established in the 
vicinity. Sooner or later, every large institution has to 
cope with epidemics of germ diseases, — typhoid fever, 
diphtheria, dysentery, etc. Having at command labo- 
ratory facilities for determining the facts regarding the 
character of such diseases, their precise locality, their 
extension or subsidence, and, by reason of such knowl- 
edge, being able to apply the exact remedy in the right 
place and at the right time, mitigates by more than 
half the worry and sense of responsibility thrust upon 
the management of the hospital by an epidemic out- 
break. Then the most delicate blood examinations 

73 



74 CARE OF THE INSANE 

should be matters of daily routine. Diagnosing certain 
diseases, producing autogenous vaccines, settling ques- 
tions of immunity, controlling dosage in the specific 
treatment of tuberculosis, etc., are among the prob- 
lems which the laboratory alone can decide and which 
ought to be decided within each institution. 
, All hospitals should be able to keep up to the times 
with pathological work. Specimens, in the form of 
mounted microscopic slides, from every diseased organ, 
in all cases examined post mortem, should be kept in 
cases so marked and numbered that any desired one 
could be found whenever needed. 

Laboratory equipments in connection with hospitals 
for the insane suggest the propriety of making research 
investigations in order to obtain more definite knowl- 
edge regarding the causation of insanity. The physical 
cause for some phases of insanity may be one of the 
obscure secrets which can be discovered only through 
experiments with the blood serum. That wonderful 
fluid is known to contain and retain so many specific 
marvels which seem not to interfere with one another 
that there is much promise for light upon some forms 
of insanity in this field of inquiry. Few, even among 
physicians, realize the superior advantages for medical 
research work to be found in the modern large hospital 
for the insane where a complete laboratory outfit is 



CARE OF THE INSANE 75 

under the management of a competent corps of medi- 
cal specialists. Very often the enthusiastic investiga- 
tor into bio-chemical secrets, physiological anomalies, 
pathological conditions and causes, works upon some 
important problem, isolated from interested associates 
who might aid him in excluding the personal equation 
and other misleading factors. Frequently he is handi- 
capped by inadequate laboratory accessories, or searches 
vainly for material enough to give the results of his 
labors a basis sufficiently broad to command respectful 
attention. But in large state hospitals every variety 
of laboratory implement can, and should, be provided. 
Working side by side and in harmonious efforts to 
secure a better understanding of the diseases they are 
investigating are grouped the clinician, the chemist and 
the pathologist, who are thus able to control or supple- 
ment one another's work. 

Besides, within the same institution walls there re- 
sides a large number of permanent patients under their 
immediate observation and absolute control, and among 
this aggregation of invalids, case after case of some dis- 
eased condition, in varying stages of development, can 
be observed. In this promising field they can work, and, 
testing out theories as they proceed, they can establish 
on a practical basis any discovery made and verify again 
and again any claims they may consider worth pub- 



76 CARE OF THE INSANE 

lishing. Research medical work in hospitals for the 
insane in its results cannot be restricted to that which 
alone interests the mental specialist. Any new fact 
established through scientific work there will be of such 
fundamental character that it will enrich the literature 
and extend the scope of general medicine. 

Unfortunately, hospitals for the insane are often re- 
garded as undesirable neighbors in a town or locality. 
Be they popular or unpopular, they can, in a large 
measure, compensate the surrounding public for their 
presence by generously permitting neighboring physi- 
cians to enjoy in their private practice the assistance 
which the hospital laboratory can render. Especially 
when hospitals which maintain first-class laboratories 
are situated in country districts, remote from centers 
where board-of-health laboratories are established to 
aid in determining many health questions vital to the 
community, they should extend to the general prac- 
titioners of medicine within a reasonable distance the 
benefits of the laboratory facilities and the skill of the 
laboratory staff. Bacteriological and pathological ques- 
tions from such outside sources should be fully consid- 
ered and the best expert ability should be at the service 
of the medical men outside the institution. Possibly 
it might be advisable to charge for such work the act- 
ual expense incurred. But if rendered gratuitously, the 



CARE OF THE INSANE 77 

hospital would profit by its benevolent intention, since 
the amount of outside work would seldom interfere 
with regular duties, and would, while interesting and 
stimulating the laboratory operators, secure the good 
will of the profession and general public. Should such 
outside work necessitate the services of an extra assist- 
ant, the additional expense would be an excellent in- 
vestment for the citizens at large, by whom such insti- 
tutions are owned and supported. 



MANAGEMENT OF PATIENTS. 

The modern large hospital for the insane, palatial in 
respect to its proportions and architecture, surrounded 
by ornamental trees, shrubs, flower beds and a beauti- 
ful landscape, with spacious, artistically decorated inte- 
riors amply stocked with comfortable furniture, is not 
intended for prison purposes. Security for the patients 
committed to his care is not, at the present day, the 
only burden of the superintendent's responsibility. 

Public sentiment requires that insane patients in hos- 
pitals shall, as far as possible, be restored to normal 
health, and that all patients, both acute and chronic, 
shall be provided with substantial comforts, shall be 
protected from abuse and unnecessary hardships, and 
shall enjoy a reasonable degree of freedom. It is well 
known that the insane were subjected to shocking 
treatment in earlier times, and no doubt insane patients 
in hospitals set apart for their proper care and treat- 
ment still suffer much at times from the hands of those 
employed to nurse and watch over them. Such abuse 
of the insane cannot be wholly suppressed until the 

79 



80 CARE OF THE INSANE 

old system of coercion, with its severe discipline and 
mechanical appliances to substantiate threats, is eradi- 
cated from hospitals for the insane, and practical com- 
passion, with gentle arts and persuasive measures, is 
adopted by the entire management, nurses and medical 
officials, as the ruling principle in managing the patients. 
The management of the insane in conformity with 
the Tuke and Conolly practice has come to be desig- 
nated as the " non-restraint" system. That term does 
not signify the whole scheme, but it suggests the key 
to this humane hospital policy, because strait-jackets, 
wristlets, bed harnesses, etc., are the obvious and tan- 
gible insignia of the harsh, repressive methods too com- 
monly enforced in hospital wards. Then, the pacific, 
mollifying arts involved in properly treating the insane 
cannot be successfully inculcated and enforced except 
where mechanical restraint is wholly discarded. There- 
fore, " non-restraint" has properly enough been accepted 
as a significant word symbol for the highest ethical 
development of hospital management in the care of the 
insane. As used by Conolly, the term means very 
much more than the absence of restraining implements. 
The essential feature of this method is the underlying 
spirit of humane endeavor which, when intelligently 
directed, will obviate the apparent necessity for using 
restraining measures by happily qualifying all the rela- 



CARE OF THE INSANE 8 1 

tions between patients and employees throughout their 
entire association. 

Strict rules admonishing nurses and attendants to 
avoid abuse of patients, abolishing instruments for me- 
chanical restraint and increasing the wages of the em- 
ployees are commendable steps towards improving the 
condition of the insane. Yet such measures will fall 
short of protecting troublesome, unreasonable patients 
in hospitals where for the greater part of the time they 
are under the absolute control of thoughtless, dictatorial 
attendants and depend for their comfort upon what 
abridged rights and restricted freedom they can obtain 
from employees. Where the ward management of tur- 
bulent patients is left largely to the discretion of attend- 
ants who have never been taught, or have never seen 
in practice, methods of controlling the insane without 
threats, and without mechanical restraint, the unwise 
attendants naturally assume that patients must be kept 
under rigid discipline, and held in such a state of sub- 
jugation that they will promptly obey any command 
given them. The ignorant and undisciplined inclina- 
tion of such employees incites them to bully the pa- 
tients, often compelling obedience to unnecessary orders 
as if simply to test their docility. And some of the 
rougher class of attendants will deliberately attack a 
new patient to give him a practical demonstration that 



82 CARE OF THE INSANE 

pain will be inflicted and many privileges will be sus- 
pended unless he passively submits to such tyrannical 
discipline. One motive for which such cruelties are 
visited upon new patients in hospitals is to early im- 
press them with a fear of consequences should they 
report to medical officials instances of abuse which 
they may suffer or may see inflicted upon other 
patients. If patients who have been badly treated by 
employees suppress the facts and refuse to answer ques- 
tions, a reign of intimidation is the most probable ex- 
planation for their attitude. When the pitiless attend- 
ant is cautious enough to fear detection, and possible 
discharge, if it becomes known that he assaulted an 
insane man, he can usually irritate and provoke the 
patient into expressing his resentment by resisting or 
striking the aggressor, and when the patient has actually 
struck the first blow his fate is sealed. Under the plea 
of self-defense the attendant can, until satisfied, safely 
pommel the innocent victim of his malicious motives. 

Public opinion is occasionally fanned into indignation 
by published reports of hospital abuses. At such times 
an investigation of the reported death or serious injury 
of some insane patient may be ordered by the governor 
or legislature. As an outcome, some employee may be 
censured and discharged, but more frequently the final 
report will minimize the outrage because the situation, 



CARE OF THE INSANE 83 

as represented by interested hospital parties, was one 
of great peril to the employee. All are led to believe 
the employee was in personal danger and simply de- 
fended himself. In the findings, the sad results of such 
" hospital accidents" are always regretted, but are 
deemed unavoidable so far as the investigators could 
judge. Such official investigations are almost always 
superficial, and the verdict serves little purpose beyond 
softening the process of closing the incident. The com- 
mittees naturally have to restrict their examination to 
details of the particular encounter which ended disas- 
trously. An advocate who could comprehend the whole 
affair and would be able to point out the defects of such 
inquiries seldom appears for the patient. In such trials 
testimony will not be adduced to show what was the 
probable fact, — that the patient was a long-suffering 
victim of irritating taunts, minor abuses and repeated 
threats which finally produced an insane craving for 
revenge, — and no one will volunteer to argue the pa- 
tient's right to defend himself when he had cause to 
believe himself in danger from a persistent enemy. As 
a rule, in all such cases the " commission " or " commit- 
tee" consider only the final result in a long chain of 
circumstances, more or less extended as to time, but all 
leading up to the logical catastrophe. 

Happily such hospital conditions are exceptional, al- 



84 CARE OF THE INSANE' ' 

though the time was when troublesome patients were 
very generally abused. It is not intimated here that 
such methods are practiced in the better-regulated hos- 
pitals of the present day. But without doubt a minor 
phase of ward despotism does exist, not infrequently, in 
some wards of most hospitals for the insane. Too often 
there exists a condition of internal affairs where attend- 
ants order patients about in rough terms, often with 
profanity, and manifest a degree of impatience that ex- 
asperates nervous invalids, who are threatened with 
removal to back wards, seclusion-rooms, or with strait- 
jackets, unless they respond instantly when addressed 
by the ward " dictator." The great majority of patients 
submit to such treatment — some meekly, some sul- 
lenly. But occasionally some irritable or semi-demented 
person will continuously ignore the commands of the 
churlish overseer. Then follow louder and more terrible 
menaces, until the baffled petty autocrat, intent upon 
maintaining his idea of discipline, strikes or seizes the 
"rebellious subject, " who may then unexpectedly show 
much fighting ability, and as a consequence some one 
gets injured, usually the poor patient. The order given 
may have been unnecessary and unreasonable, but once 
engaged in a contest to demonstrate his autocracy, the 
attendant, if a novice, will be anxious chiefly to main- 
tain his assumption of power and his false conception 



CARE OF THE INSANE 85 

of dignity, failing entirely to anticipate the "accidental" 
or natural consequences. In such positions, "experi- 
enced," hardened attendants will proceed in the same 
way, disregarding all chances of serious results to the 
patient, confident that they can mislead officials re- 
garding their responsibility. The cases where patients 
resent such harsh, imperious discipline by physical re- 
sistance may be infrequent, but the hardship and injus- 
tice incident to such ward management, when visited 
upon large groups of patients, aggregates an immense 
sum total of unhappiness and misery which might be 
obviated by the substitution of rational methods by 
which to control insane patients. 

And yet, the attendants who inflict such discomfort 
and misery have some defense for their conduct. The 
hasty, arbitrary measures enforced by the average state 
hospital ward attendant may represent his best judg- 
ment and be the measure of the meager or erroneous 
instruction he has received, as well as the faulty char- 
acter he is developing for himself because of inadequate 
instruction and incompetent guidance. To insure the 
proper treatment of the insane in large hospitals, the 
individual members of the nursing staff should have 
their ideas trained to understand the propriety and the 
importance of controlling patients by gentle, persuasive 
measures. Their sympathies for the patient should be 



86 CARE OF THE INSANE 

awakened and cultivated. They should be inducted 
into the practice of leading patients by suggestion, de- 
liberation, conscious mental power and the advantages 
of position. They should take professional pride in 
winning mental victories over the turbulent insane and 
deplore the subjugation of confused and terrified insane 
men and women by using brute force and strait-jackets. 
In managing insane patients, measures calculated to in- 
spire confidence should be adopted when possible; but 
it is no more necessary to reveal the whole truth to them, 
upon all occasions, than it is proper to keep sane patients 
informed of every shade of opinion concerning their 
cases which may be entertained by their medical at- 
tendants. With the insane it is important to engage 
their attention and if practicable secure their coopera- 
tion. 

With some patients the simple truth will serve every 
purpose, but with certain others it will not succeed and 
diplomatic methods must be called into requisition. 
Only unsympathetic physicians will at all times dis- 
close their conceptions of personal facts to insane pa- 
tients. Hope and confidence in the insane can seldom 
be developed through such mistakenly honest inten- 
tions. In truth, such brutal frankness could be ex- 
pected from those only who discover nothing but good 
in using strait-jackets. It may be true that hospital 



CARE OF THE INSANE 87 

physicians often criticize those who use deception in 
committing patients to hospitals for the insane, and it 
is seldom wise or necessary to do so; but there are in- 
stances when painful and even serious consequences to 
the patient and his friends may be obviated by resorting 
to stratagem and diplomacy. 

When persons fully recover from insanity they will 
show no resentment against old friends who in the try- 
ing process of incarceration obscured the truth. How- 
ever captious respecting the conduct of patients' friends 
in this respect hospital physicians may be, it is safe to 
assume that those with experience seldom go through 
their own wards addressing and replying to the patients 
with literal candor. Of course no self-respecting physi- 
cian treats his patients having mental disorder by falsi- 
fying. Yet he should vary his style of communication 
and exercise more or less reservation to pertinently meet 
the complex mental conditions with which he has to 
deal. He should guard his tongue and not tell too 
much truth. He should often mask his opinions and 
be prepared to veto patients' whims, baffle their inten- 
tions and evade their direct questions without defi- 
nitely committing himself or arousing their antagonism. 
To command the situation at all times, he will have 
frequently to insinuate and suggest rather than affirm, 
employ figurative speech freely instead of giving cate- 



88 CARE OF THE INSANE 

gorical answers, and project captivating schemes befit- 
ting the humor of the patient or his mental peculiarities. 

Many patients, incoherent or demented, have no 
power of discrimination, while others may be exceed- 
ingly penetrating and subtle. Hallucinations and delu- 
sions should be kindly corrected, again and again, by 
cogent, logical explanations. Not that truth and reason 
will certainly dissolve such errors of sense and judg- 
ment, but they do have weight in some cases. 

Sufferers from mental depression need mental stim- 
ulus, and to them attractive and interesting subjects 
should be so charmingly presented as to evoke thoughts 
along new channels. Restless, overactive cases should 
have provided a safe outlet for their excessive kinetic 
energy, which cannot be thwarted but can be modified 
and diverted. 

Manic cases with an exaggerated ego and prolific 
activities, playfully rather than viciously inclined, can 
always be induced to expend their augmented mental 
and physical force in some harmless way. Such cases 
usually puzzle the physicians, and worry the employees, 
as they become naturally rebellious under strict disci- 
pline. But they are always tractable when properly 
handled. For them some unusual and interesting line 
of conduct should be devised, — something congruous 
with their prevailing conceit. They are easily be- 



CARE OF THE INSANE 89 

witched with a notion of doing something fantastic or 
most exceptional, and under a giddy exterior often re- 
tain a semi-correct sense of propriety and a whimsical 
code of honor. 1 

Such cases cannot be expected to conform to a rigid 
system of ward discipline. The hospital management 
ought to be sufficiently elastic and reasonable to pro- 
vide exceptions and variations adapted to the individual 
requirements of these exacting patients. This class of 
patients is never large and the acute condition is seldom 
prolonged. They generally recover in time and recol- 
lect all that transpired during their mental excitement. 
The author of " A Mind That Found Itself" most graph- 
ically describes the mental conditions of such a case. 2 

"Non-restraint" in its literal, narrow sense may be 
made the rule of an institution without bettering the 
treatment of the patients. There are other processes 
more painful and more dangerous than wearing the 

1 See illustrative case reported in the Appendix. 

2 "A Mind That Found Itself," an autobiography by Clifford W. 
Beers, published by Longmans, Green & Company, 443 Fourth Ave- 
nue, New York City. In this book the author tells of his experi- 
ences while a patient in sundry private and public hospitals for the 
insane during the years 1900-1903, and suggests a plan for a national 
movement in mental hygiene, and for the improvement of conditions 
among the insane. This plan has since been put into effect under the 
auspices of the National Committee for Mental Hygiene, which has 
come into existence as a result of the publication of "A Mind That 
Found Itself." 



90 CARE OF THE INSANE 

camisole, which can be employed by tyrannical attend- 
ants to frighten and intimidate defenseless patients. 

Doubtless patients will occasionally present critical con- 
ditions which seem to necessitate mechanical restraint, 
and when the use of such appliances would result 
in no injury, mental or physical, to that particular pa- 
tient. Could the treatment of such a case be entirely 
dissociated from all other cases in the minds of the 
physicians and nurses, the use of straps and jackets 
might be regarded as unobjectionable. But in institu- 
tions for the custody of the insane, the general welfare 
of the whole body of inmates depends very much upon 
the morale of the nursing staff, and with its members 
the demoralizing effects of making exceptions to the 
" non-restraint " rule are so pernicious and wide-reach- 
ing that yielding to the use of mechanical restraint with 
occasional patients would sacrifice the best interests of 
a multitude of other cases having equal claims upon the 
management for protection from unnecessary restraint 
and ignominy. The superintendent who imagines he is 
controlling the use of mechanical restraint in the hospital 
where he directs affairs, when he reserves to himself 
the power of deciding whether mechanical restraint 
can be used in any given case, does not see himself as 
others see him. Even the nurses understand the situa- 
tion better than he. They clearly realize that the 



CARE OF THE INSANE 91 

judgment of such officials on this point of restraint is 
always an inspiration from themselves. 

He receives by messenger, or through the telephone, 
a report from nurses that some patient is desperately 
suicidal or dangerously maniacal, with a request that 
permission for restraint be granted. He dare not decide 
against their evident wishes under such circumstances. 
The nurses may assume to be physically incapable of 
further effort. The executive chief is mentally and 
morally helpless when thus appealed to unless he has 
previously established the " non-restraint" treatment as 
the undeviating working practice in his hospital. 

Occasionally a medical superintendent who believes 
in the use of mechanical restraint, for exceptionally 
trying cases at least, will cite an affray with an insane 
patient, stating conditions which actually confronted 
the attendants, and request a solution of the situation 
from some " non-restraint" advocate. Such superinten- 
dents misapprehend the "non-restraint" theory. It is 
possible that nothing short of some form of restraint or 
seclusion would instantly meet all the requirements of 
the case as described. The correct and the better 
method had been too long neglected. Rational treat- 
ment should have been applied to the case reported 
weeks, months, possibly years, before such a violent 
culmination of threats and neglect by incompetent em- 



92 CARE OF THE INSANE 

ployees occurred. The cure for such troubles consists 
in educating nurses and attendants to become true 
nurses, with a thoroughly humane conception of their 
duties. They must be willing to follow helpful sugges- 
tions and apply correct principles in efforts to influence 
rather than coerce the insane over whom they have 
charge. While the superintendent who asks in sincer- 
ity how nurses are to extricate themselves from impend- 
ing conflicts with patients without using force may feel 
justified in his attitude with the answer he receives, by 
his question he unwittingly exposes to the experienced 
" non-restraint " patron the prevailing lack of proper 
system of ward management in his own institution. 

The superintendent who seriously desires to avoid 
the use of mechanical restraint will have not only to 
forbid and abolish it, but to keep a careful watch over 
the nurses and their dealings with patients, especially 
in those wards where new and troublesome cases are 
located. The number of patients likely to get into 
trouble with the nurses is not large in any one well-con- 
ducted hospital, and concerning the treatment of these 
the superintendent can and should exhibit constant 
solicitude. He should personally investigate every in- 
stance of violence between nurses and patients and keep 
a record of his findings. This can be done by requiring 
all employees to report in writing, and without delay, 



CARE OF THE INSANE 93 

every instance of accident to or trouble with a patient. 
Special blank cards for this purpose should be in the 
hands of all nurses, to be filled out in every case of fric-. 
tion with a patient. 1 These cards the superintendent 
should file under the patient's name after having made 
a personal investigation of the affair reported. This 
means additional burdens of care, labor and responsi- 
bility for him, but the best interests of the patients re- 
quire it and the interested public should expect nothing 
else. Unless the superintendent takes an active part 
in organizing and conducting a " non-restraint" cru- 
sade, the work will be superficial and spasmodic. Nurses 
will lack continuous initiative unless stimulated by his 
interest in the general scope and many details of this 
policy. He will need to utilize the services of deputy 
assistants and supervisors who understand his views and 
who can be trusted to act with intelligence and loyalty. 
It is imperative that all wards, in which are placed 
patients likely to give trouble, should be under the 
charge of head nurses in every way competent to man- 
age patients without restraint and who are willing to 
teach their ward helpers the art, its principle and the 
details of its application. Such head nurses must them- 
selves scrupulously observe all the requirements, or they 
will weaken their influence and control over their ap- 
prentices. Irresponsible employees could be quickly dis- 
1 See Card Index in Appendix 



94 CARE OF THE INSANE 

posed of and the abuse of patients could be effectually 
checked if only a number of such head nurses in each 
hospital placed at strategic points would faithfully re- 
port each instance of infraction or neglect of duty. In 
most hospitals for the insane there prevails among nurses 
a fictitious sense of honor which favors employees and 
does not protect or vindicate the patients. 

The superintendent should in all possible ways adopt 
plans which will facilitate the successful working of 
the ' ' non-restraint ' ' policy. The overcrowding of wards, 
especially those appropriate for the care of noisy and 
fractious patients, should be avoided. He may not be 
able to regulate admissions to the institution, but over- 
crowding is such a serious interference with skillful 
nursing he should register his protest when conditions 
prevent the best work. 

The proper classification of those patients likely to 
cause trouble is a great aid to the " non-restraint" meth- 
ods. Not that all disorderly inclined patients should be 
herded in back wards, for irritable patients react upon 
each other and should be frequently changed from ward 
to ward so they may engage in forming new compan- 
ionships and avoid tiresome associations. In making 
such changes, personal antipathies between patients, 
or patients and certain nurses, should receive consid- 
eration. But nurses should not be permitted to force 



CARE OF THE INSANE 95 

such changes where it is evident they are chiefly con- 
cerned to rid themselves of the care of troublesome 
patients. Unless some patients are transferred from a 
noisy to a quiet ward before the excitement has wholly 
subsided, their convalescence may be retarded. Such 
a transfer from back to front ward, and then returning, 
repeated several times, is often the correct way to stimu- 
late them to exercise self-control. Seclusion may be 
necessary at times, but it should be remembered that 
prolonged seclusion is bad practice. The shorter the 
period of seclusion, as a rule, the better the effect upon 
the disturbed patient. Noisy, destructive patients are 
seldom improved by solitary confinement. Exercise out 
of doors to the point of physical fatigue, with a compe- 
tent guard of nurses, is a much better form of isolation 
from other patients, and a practical way of treating 
such cases. Ample facilities for prolonged warm baths 
must be provided. When the temperature of the water 
is maintained a degree or two below blood heat there is 
little risk of heart failure. 

Persistent destruction of clothing is fostered, not cured, 
by the use of ill-fitting canvas dresses. Better supply 
material having bright colors and striking figures — 
something that will appeal to what vestige of pride may 
exist — that will attract the eye and, possibly, alter the 
purpose of the victim of destructive habits. 



96 CARE OF THE INSANE 

Daily out-of-door exercise for all able-bodied patients 
should be insisted upon whenever the weather is suit- 
able, and all patients who are physically able to work 
should be urged to engage in some form of labor, at 
least a part of each day. Let those who object to 
physical exertion accompany those willing to labor, even 
if at first they simply stand around and watch the busy 
workers. Under such circumstances, the influence of a 
good example is suggestive, frequently inducing idlers 
to participate in useful employment. Patients who 
work faithfully and diligently should receive some re- 
ward. Occasionally, a small sum of money regularly 
paid as a gratuity will secure their good-will and stim- 
ulate their exertions. Special diet, extra clothing, to- 
bacco, occasional excursions, may be profitably granted 
as inducements to render efficient and continued service. 
Compelling patients to work should be strictly forbid- 
den, as serious conflicts have resulted frequently through 
attempts on the part of attendants or nurses to force 
patients to serve them at ward duty or in performing 
some disagreeable task. Inducing patients to work or 
to conduct themselves properly through gifts, rewards 
or favors is a prominent and legitimate feature in the 
" non-restraint" system. Head nurses over all wards 
where restive and seemingly obstinate patients dwell 
should be liberally supplied at all times with extra food, 



CARE OF THE INSANE 97 

fruit, candy, pictures, etc., for use in distracting the 
attention of excited patients and as a ready means by 
which to establish friendly relations with patients who 
are suspicious. 

It may be proper to keep medicines in each ward 
under the care of the head nurse, but dangerous drugs 
— those with which suicide could be effected — had 
better be elsewhere or securely placed. Medicine in- 
tended to produce quiet and sleep should be kept in 
the administration drug room. The more free the use 
of hypnotics with the insane, the more noisy they are 
at night and the greater the demand for more hyp- 
notic medication. By the use of such drugs a tempo- 
rary, quieting effect may be produced, but the reaction' 
which usually follows intensifies the original condition, 
and patients thus indulged become impatient for a 
repetition. Hypodermic medication of this class should 
seldom be employed, as a drug habit is easily contracted 
and tenaciously held. Hypodermic needles and tablets 
should not be entrusted to the nurses lest some patient 
some day get a hypnotic injection that was not ordered 
by the physician. 

Nervous, restive patients should be assigned to large, 
roomy wards whenever possible, so they may freely 
roam about, greet new acquaintances before they tire 
of enforced companionship and vent some explosive en- 



98 CARE OF THE INSANE] 

ergy while aimlessly tramping about the long wards. 
Cramped accommodations and restricted movements are 
decidedly irritating to the insane and should be avoided 
except when exhaustion is likely to supervene upon too 
prolonged physical exertion. Noisy, talkative persons 
should be taken into the fields and woods to correct 
their unpleasant habits, not consigned to out-of-the-way 
dark rooms. The more close the restrictions, as when 
in a cell or strait-jacket, the more intense the irritation, 
fear and suffering; consequently the more persistent 
the noise and the louder the shouting. As a result of 
natural laws, it is to be expected that painful mental 
tension incident to extreme limitations of space or mo- 
tion will gradually relax, to be succeeded by a sense of 
relief and quiet as the restrictions are mitigated and 
gradually transformed into a state of freedom. 

The relation of instinctive mental conditions to vary- 
ing degrees of space ought to be considered in planning ac- 
commodations and treatment for the insane. A greater 
number of nurses should be employed when mechanical 
restraint is abolished, as the duties and actual labor 
with excitable and depressed patients are increased un- 
der the "non-restraint" methods. In large wards, ac- 
commodating acute or intractable cases, nurses should 
be constantly posted at several points about the room 
in order to suppress quarrels among patients and to 



CARE OF THE INSANE 99 

detect violent conduct in its incipient stage. Patients 
with suicidal tendencies should be assembled in a special 
ward or dormitory where continual watch can be kept 
over the whole company, both day and night. Their 
every movement should be under trained observation. 
Practically all departments for patients should be kept 
under strict watch at night. Night supervisors and 
night watchmen should be employed and competent 
nurses should be kept both day and night in all 
wards occupied by untrustworthy patients, so the old 
practice of locking patients in single rooms at night can 
be discontinued. Watched dormitories are more suit- 
able sleeping places for the majority of patients than 
ordinary single rooms. There cannot be too much 
watchfulness in hospitals for the insane. No power 
on earth so effectually controls the conduct of men as 
human vision, and so the eye of a qualified nurse aided 
by a prudent tongue can control nearly all insane pa- 
tients without any physical exertion. 

There are good reasons why it is advisable to open 
hospitals for the insane to the public often and fully. 
When public inspection or visiting days recur frequently, 
the nurses are stimulated to keep their wards in a pre- 
sentable condition, as they know the general appearance 
of the halls and rooms, as well as the patients' cloth- 
ing, will fall under critical observation. This constant 



IOO CARE OF THE INSANE 

anticipation keeps both nurses and patients more 
active and more cheerful than would the dead level of 
hospital routine. The patients' hopes are awakened 
and their spirits are stimulated by coming into close 
contact with people of the outside world. When pub- 
lic visiting days occur twice weekly, as in some institu- 
tions, and a large number of strangers pass through the 
wards each open day, the patients become so accustomed 
to the spectacle that they regard the visitors with com- 
paratively little curiosity, maintaining a good degree of 
dignity and seldom exhibit undue excitement. With 
frequent repetitions, the sight of outsiders becomes a 
simple matter of course and the patients appear self- 
possessed and natural, while patients who seldom meet 
strangers will flock about a visitor in their wards, many 
talking at the same time, each intent upon securing 
recognition or exacting some promise. 

Properly conducted hospitals for the insane no longer 
afford such grotesque and shocking spectacles as, ac- 
cording to Pepys and Hogarth, were on exhibition in 
old "Bedlam." No doubt many persons at the present 
day are prompted to visit hospitals for the insane out 
of curiosity, but the tables are practically turned in 
hospitals where frequent ward visiting is the rule: the 
parading visitors provide the exhibition. Their evident 
timidity and unconscious stupidity often interest the 



CARE OF THE INSANE IOI 

patients, who quietly note and enjoy the passing show, 
which they may subsequently criticize or analyze with 
jest and merriment. Besides, it is a needed and valu- 
able object-lesson to the public. The world at large 
still entertains too many exaggerated and erroneous 
opinions concerning the internal conditions of such 
institutions. When the visitors enter the better-class 
hospitals and walk through ward after ward without 
detecting anything remarkable, it is a revelation to 
them. They note the large, pleasant living rooms, well- 
furnished tidy sleeping rooms and attractive dining halls, 
with appointments, in many respects, superior to those 
provided in the patients' homes. They observe the 
scrupulous cleanliness which generally prevails, the pic- 
tures and ornaments displayed in most wards, and are 
especially impressed with the natural appearance and 
good behavior of the patients. In this way they re- 
ceive impressions and carry away convictions which go 
far towards correcting the prejudicial traditions con- 
cerning such institutions, which have been treasured 
and often repeated in the very circles represented by 
such visitors. 

Friends of patients err when they deprecate such pub- 
licity for the insane confined in hospitals. Few of the 
insane are sensitive respecting their condition, and the 
majority pine for friendly associations. False pride 



102 CARE OF THE INSANE 

should not be permitted to immure them so completely 
as to cut them off from sight and sound of sane life, and 
permit them to see only the faces of their fellow patients 
and custodians. The greater the publicity of the man- 
agement, the less opportunity there is for injustice to 
the patients. As a rule, visits from strangers have less 
objectionable results upon the patients' mental condi- 
tion than frequent visits from near relatives. Rela- 
tives and friends cannot understand why their visits to 
the mentally sick should produce harmful results, and 
yet such is the frequent outcome of premature or too 
frequent visits by injudicious kindred and friends. 
Convalescing patients are likely to be set back by a re- 
vival of emotions linked with family associations, and 
many chronic cases are kept in a state of unrest and 
smothering rebellion through unwise sympathy and ill- 
expressed friendship proffered by timid kindred. 

Hospital life is necessarily monotonous, and liberal 
diversion is the rational antidote with which to counter- 
act its bad effects. Amusements varying in character 
should be provided at short and regular intervals for the 
entertainment and mental relaxation of the patients. 
Anything which agreeably enlists and engrosses the 
attention fulfills the requirements. Music and dancing 
can always be depended upon to produce satisfactory 
results. 



CARE OF THE INSANE 103 

A congregate dining room can be utilized to add vari- 
ety to the patients' daily life, to change the drift of 
morbid thoughts and inclinations, and to introduce nor- 
mal conditions as fully as possible into hospital meth- 
ods. Both male and female patients should be accom- 
modated in the same dining room, their tables being 
separated by a wide passageway through the center of 
the hall. No kind of food should be placed upon the 
tables until all have been seated. Food can then be 
distributed from rubber-tired cars in the center aisle, or 
be served from sideboards against the walls, by selected 
patients acting as waiters, one waiter to each table. 
The meals should be so planned that the food can be 
served in a number of courses, the more table etiquette 
the better, allowing fully one hour for dinner and forty- 
five minutes for breakfast and supper. In such dining 
rooms haste is objectionable, and five hundred to fifteen 
hundred patients can be managed and be properly fed 
with ease and quietness. The time patients thus spend 
at table and consume coming from and returning to 
their wards will amount to at least three hours a day. 
An orchestra should be employed to furnish music 
all the time patients are present, morning, noon and 
night. Only those who have had experience with such 
meal arrangement can appreciate the power this method 
of meal serving has towards promoting the self-respect 



104 CARE OF THE INSANE 

of the individual patients and tranquilizing ward condi- 
tions throughout the whole hospital. The aim and pur- 
pose of such dining-room practice should be to cultivate 
good table manners, to occupy the patients' time agree- 
ably, to increase the self-respect and self-control of the 
patients by adopting as fully as possible the dining- 
room customs of large aggregations of normal people. 
Incidentally, it allows ample time for quiet meals to be 
served attendants and nurses, usually in one section of 
the same room. It also removes from the living wards 
objectionable odors and annoying housekeeping duties, 
and, last to be considered, it is decidedly economical as 
regards cost for food, waste and service. 

The music is an important, probably an essential, fea- 
ture. Many patients listen with pleasure, and it affects 
the outward manifestations of all present. Without 
music there would be more noise, more loud talking, and 
some patients would find it difficult to repress an inclina- 
tion to lecture the officials or others present, and make 
statements leading to rejoinders and disputes. With 
attractively arranged tables surrounded by plants and 
flowers, and with neatly attired patients, entertained by 
good music, little more is required to make the congre- 
gate dining room the acknowledged social center of the 
establishment, from which will emanate good influences 
to tone and characterize the whole institution. 



NURSING STAFF. 

In hospitals for the insane the patients have to de- 
pend chiefly upon the nurses for sane companionship, 
as the medical officers can of necessity devote but little 
time to individual cases. Therefore, the general intel- 
ligence and natural disposition of the nurses, supple- 
mented by their conceptions of duty and knowledge of 
nursing the insane, determine, in a large measure, the 
domestic and social atmosphere by which the patients 
are surrounded during their whole hospital residence. 

All superintendents appreciate the importance of se- 
lecting employees with especial care as regards their 
qualifications for the trying positions offered them, but 
the fact that preliminary arrangements with hospital 
employees have in most cases to be negotiated by corre- 
spondence renders it impossible to cull from the list of 
applicants only those who can be depended upon to 
make satisfactory nurses. Objectionable candidates may 
be occasionally barred by requiring in advance a condi- 
tional contract, duly signed, in which the applicant 
agrees to observe all the rules and regulations and to 
obey all orders, written or verbal, issued by the hos- 
pital authorities. 



106 CARE OF THE INSANE 

It is to be regretted that ambitious young women 
with a high-school or collegiate education do not more 
generally become interested in this special work, which 
is well compensated and which offers numerous oppor- 
tunities for promotion. Women superintendents of gen- 
eral hospitals and training schools for nurses are always 
in demand at liberal salaries. 

While some of the duties in state hospitals are ad- 
mittedly unpleasant, there are compensations other than 
the financial consideration to interest and repay the 
faithful worker in such hospital wards. Under present 
conditions and the ordinary understanding as to what 
such positions offer, this service attracts young country 
people more than other classes of wage earners, as the 
wages paid are higher than in agricultural or domestic 
pursuits and where only more laborious situations are 
open to them. Beginners in stores and factories usually 
receive less remuneration for labor than the hospitals 
pay. Hospitals have to depend largely upon much in- 
competent, inexperienced help, since nursing the insane 
seems to present little attraction for other classes of 
wage earners. 

Then, of the many who engage in hospital ward work, 
few remain in the service longer than six months, and 
the ranks of the nursing staff are continuously recruited, 
almost wholly from country districts. But how to se- 



CARE OF THE INSANE 107 

cure a better class of nurses to care for and manage the 
insane is not simply a question of advancing the scale of 
wages, although more thoroughly competent graduates 
from the training schools should each year be induced 
to remain in the service by a liberal increase of salary. 
Higher initial wages would accomplish very little, as 
few candidates who could command equal wages by 
teaching or clerking would willingly submit to the dis- 
cipline necessary to fit them for successful nurses in 
hospitals for the insane. If increasing hospital wages 
did secure employees with a higher grade of education 
and better general information, such broader mental 
experience in itself fits no one for ward service in hos- 
pitals for the insane. Men and women thoroughly com- 
petent to care for and manage the insane are never born 
with perfect endowment for that peculiar service, nor 
can such qualifications be developed outside hospital 
wards. 

When inexperienced employees enter upon ward duties 
they are usually supplied with a rule book which con- 
tains many fundamental laws intended to regulate their 
general conduct towards the patients. Concerning the 
treatment of patients who give trouble, certain prohibi- 
tions will be recorded in these booklets, but such man- 
uals give scant information as to the correct principles 
of nursing those suffering from mental disorder. Indeed, 



108 CARE OF THE INSANE 

in many training schools little attention is given to this 
special and most important branch of mental nursing. 
Pupils are expected to acquire all that is necessary in 
this direction by ward experience. The consequence is 
that in most hospitals for the insane the majority of 
attendants and nurses are poorly prepared for the diffi- 
cult and perplexing tasks they are occasionally com- 
pelled to undertake. 

Young men and women, with an education no better 
than the country common school affords, with such 
mental and moral discipline only as may be derived from 
isolated family life in rural abodes, and with no practical 
experience in adjusting themselves to a social environ- 
ment where the ordinary rights and privileges of each 
individual may conflict in some manner or degree, are 
placed in wards crowded with insane patients and are 
assigned duties the discharge of which would at times 
tax the mind of a mature philosopher and the heart of 
a veteran in philanthropic work. It is not surprising 
that they frequently make a sad failure of the under- 
taking. In earlier hospital days, some attendants, by 
long experience and with good counsel, became pro- 
ficient workers with insane patients in hospitals, be- 
cause of their inborn capacity and love for the work. 
But now hospital demands for employees are so great 
that the necessary number of willing and apt pupils 



CARE OF THE INSANE 1 09 

must be obtained from any possible source and then be 
carefully taught the theory and practice of mental 
nursing, if better results are to be required of hospital 
management. 

The ordinary nursing instruction given in the aver- 
age nurses' training school is useful knowledge and an 
excellent foundation for practical experience in high- 
class work. But as a preparation for proper work in 
hospitals for the insane, pupils must be drilled upon the 
proper attitude the nurse should assume towards the 
insane upon all occasions. They must be taught much 
that is scarcely considered in the nursing books. They 
must be induced to school themselves in habits of self- 
control. They must be made to comprehend that phi- 
losophy which teaches how to conquer the perversities 
of human nature by indirect means rather than by pro- 
hibition. They must become proficient in overcoming 
evil notions by the substitution of good ideas in the 
minds of their patients. They must by practice acquire 
skill in a difficult art, — the art of leading by clever sug- 
gestions obstinate human beings whom no living person 
could drive. Nurses commencing this form of hospital 
work should be early impressed with the difficulties and 
trials before them, as well as the ample rewards awaiting 
all who finish the course and graduate after two or three 
years of study and ward work. Their personal ambition 



HO CARE OF THE INSANE 

and enthusiasm regarding this work should be cultivated 
through repeated graphic representations of the advan- 
tages — educational and characterise — which nurses 
may expect to derive by following after high ideals in 
nursing and managing insane patients. 

The unfolding and interpretation of this art of nurs- 
ing instruction cannot be entrusted solely to supervisors 
and principals of training schools. The executive chief 
of the whole establishment, the superintendent, must 
interest himself deeply and work industriously if he 
hopes to develop in his hospital wards the right hospital 
spirit and the better ways of nursing. 

If humane methods are to prevail in hospitals for the 
insane, nurses must be allowed to take some risks with 
bad patients, and this they cannot be expected to do 
without the approval of the superintendent. They must 
act for him in such work, and he must be ever ready to 
support and defend all subordinates who conscientiously 
and intelligently endeavor to manage the insane with- 
out restraint or other harsh measures. 

The outlines of a desperate case and some of the 
methods employed to change the patient's mental habit 
will suggest the dangers involved and the necessity 
for deviating from hospital routine in caring for such 
cases. 

A seventeen-year-old girl from the West Indies drifted 



CARE OF THE INSANE III 

into a state institution. She had occasional epileptic 
attacks with some hysterical indications, and suicidal 
impulses persistently recurred. While the convulsions 
were infrequent, for days at a time she would appear 
morose, nervous and irritable. During such spells she 
sometimes made vicious attacks upon nurses and unless 
closely watched would endeavor to strangle herself by 
twisting articles of clothing, twine, or strips of cloth 
about her neck. She often packed rags, paper and 
small articles in her mouth, nose and throat, and so 
stealthy were her movements that nurses in the room 
with her sometimes became aware of her suicidal at- 
tempt only when her face became dusky as the result of 
obstructed respiration. 

This case gave the doctors and nurses an endless 
amount of trouble and anxiety. They feared the girl 
would kill herself unless her hands were restrained by 
mechanical appliances. But she was so unusually supple 
she could squirm out of any ordinary restraining appa- 
ratus. Yet in time they devised a special bed harness 
from which she could not escape. After several months 
of such confinement she was removed, by official orders, 
to another institution where the " non-restraint" system 
of treating patients had been adopted. 

The nurse who conducted the transfer said the change 
was made because at the first institution they " could do 



112 CARE OF THE INSANE 

nothing with the patient." When asked if mechanical 
restraint had been employed, she replied, "Yes, she has 
been allowed out of it only two hours each day." In the 
second institution this patient remained three or more 
years, being at no time subjected to mechanical or chem- 
ical restraint. Such a record was possible only as the 
result of concerted work by the superintendent, assist- 
ant physicians and the nurses. Naturally the most 
difficult part fell to the lot of the nurses. They were 
given to understand that the case was certain to test 
" non-restraint" nursing, and their best efforts were 
enlisted. The nurse in charge became devotedly in- 
terested, and her personal attentions to the case repre- 
sented vigilance personified. She possessed unusual tact, 
was fertile in devising expedients, and fathomed human 
motives with facility. She quickly discerned that van- 
ity was the patient's distinctive characteristic, and this 
furnished a clue to the proper method of procedure cal- 
culated to regenerate this uneducated but cunning epi- 
leptic. The girl was praised and flattered upon all pos- 
sible occasions, and constant efforts were made to give 
her pleasure and encourage her self-esteem. All con- 
spired in a laudable spirit to give her special attention. 
She was provided with pretty dresses, decorated with 
ribbons, and scented with perfume. When nurses went 
out for a day they usually brought her some present 



CARE OF THE INSANE 1 13 

such as candy, fruit, cheap rings, beads, etc. They 
secured special articles of food for her and invited her 
to share their extra lunches and little feasts, and all 
made a pet of her. The ward physicians aided in these 
plans by giving her special prominence and compliment- 
ing her good appearance. They would accept from her 
reports concerning other patients which had been sug- 
gested by the nurses. 

To encourage her self-esteem, nurses often requested 
her to watch some troublesome patient, and found they 
could depend upon her good conduct and fidelity when 
her usefulness was thus magnified. They gave her the 
use of a drawer with a private lock in the linen room, 
and permitted her to wear the key on a tape around her 
neck. They often requested her to keep their small, 
personal belongings, and never was such confidence mis- 
placed, while she would pilfer from nurses in other 
wards without hesitation. 

She was frequently taken out of doors for special 
walks, to the storeroom for ward supplies or personal 
knickknacks and to the greenhouse for flowers. As her 
general conduct improved, she was taken to the congre- 
gate dining room for meals and to the weekly dance. 
On such occasions she was decked out with especial 
care, and often wore by permission a nurse's watch or 
other jewelry. To arouse her from her morbid brood- 



114 CARE OF THE INSANE 

ings, the nurse sometimes gave her the ward key and 
requested her to visit other wards to convey a message 
or receive a report. This was done at times when the 
nurse had so little confidence in the patient that a pre- 
vious arrangement was made with the other nurse to 
put night locks on outside doors and to watch the 
patient carefully. Gradually under such influences her 
despondent periods became less frequent and less pro- 
longed, and in time she actually enjoyed limited parole 
outside the hospital wards. 

After several years spent under such friendly and 
stimulating associations, she was again officially trans* 
ferred to another institution. 

Room for acute cases was urgently needed in the 
hospital, and, mindful of her epileptic infirmity, she was 
this time taken to an asylum for chronic cases. But 
the asylum management continued the methods em- 
ployed in institution No. 2. She was constantly under 
kind, judicious watch. She was provided with toys, 
amusing games, attractive pictures, bright-colored orna- 
ments, etc. As a rule she responded to such pleasant 
surroundings in a satisfactory manner, but on several 
occasions while in the last institution she almost suc- 
ceeded in committing suicide. Eventually, however, 
her improvement was so pronounced that the state 
authorities deemed it prudent and justifiable to deport 



CARE OF THE INSANE] 115 

her to her native island, where her brother lived and 
was to take charge of her. 

The special attention given this case was costly to 
the state and burdensome upon officials and nurses, 
and yet it was money well expended and personal efforts 
well directed. Of the many nurses who freely gave, to 
this afflicted child, mind and heart service which riches 
cannot command, none ever regretted her contribution 
or failed to reap her reward. The moral effect of such 
a triumph over serious mental conditions was well worth 
the state's financial investment for the good it accom- 
plished in the two institutions which faithfully endeav- 
ored to discharge their moral obligations to a thankless 
alien. 

Officers and employees must be impressed with the 
paramount importance of gaining the patient's confi- 
dence and good-will through kind measures and gentle 
treatment, at and from the time they enter the hospital. 

Beginning in the right way with new patients is all- 
important, but unfortunately for nurses as well as pa- 
tients current rumors of hospital iniquities and popu- 
lar prejudice against employees in hospitals for the 
insane are so widely spread and so deeply seated that 
very many patients enter such institutions with a keen 
apprehension of ill usage and punishments to come. 
The science of mental nursing emphasizes the impor- 



Il6 CARE OF THE INSANE 

tance of neutralizing as quickly as possible the baneful 
effects of such painful anticipations. Arguments with 
distracted individuals will not dispel such enthralling 
vagaries. Substitution is the only effectual remedy. 
The patient's mind must become preoccupied with ideas 
of an opposite character. He must be favorably im- 
pressed by persistent kindness. Agreeable surroundings 
and reassuring observations must serve to crowd his 
dismal forebodings into the background of his thought 
and memory. Unless this rational, humane method be 
adopted, the patient will retain his horrifying convic- 
tions and possibly reenforce them by unfortunate expe- 
riences. Under such regrettable conditions, the patient 
may naturally come to view the ordinary conduct of 
the nurses in the light of his preconceptions. Atten- 
tions to himself, prompted by kind motives, may be 
misunderstood and be resented. Gentle attempts to 
aid him in undressing and dressing, in bathing or serv- 
ing food, will be magnified and distorted by his dis- 
ordered imagination and faulty reasoning into assaults 
and homicidal designs. Such vagaries he will firmly 
believe, and his conduct will accord with them. If he 
does not completely recover, he will always retain such 
convictions and subsequently relate them to friends 
and others as facts. Who could reasonably expect to 
sooth and quiet a distracted person, or reassure a wor- 



CARE OF THE INSANE 117 

rying and suspicious insane man, by sharp commands, 
hustling movements, and threats of a dark room or 
the strait-jacket? And yet such are the means which 
naturally seem proper for the purpose to the nurses 
and laymen who are ignorant concerning better meth- 
ods, or who feel they possess an agency in mechanical 
restraint with which the obdurate patient can be effec- 
tually subdued. It is this conscious command of effec- 
tual physical power held in reserve that destroys the 
making of a good nurse in hospitals when straps and 
strait-jackets are allowed. When a nurse is certain 
that a patient can be humiliated or rendered helpless at 
her pleasure, by the application of ties, straps or canvas 
jackets, she will not long tolerate unkind and abusive 
words from the patient. She will not tax her strength 
and mental power in attempts to calm the patient's 
excitement with soothing words. She will not suffi- 
ciently exert herself to divert the patient's attention. 
Neither will she bestow upon the confused or distressed 
patient genuine sympathy, the indulgence and cultiva- 
tion of which serve important functions in improving 
the character of the nurse while it is often effectual in 
awakening the better sense of the patient. When em- 
ployees make frequent use of strait-jackets on patients 
that are noisy, destructive to clothing, or violent, they 
sacrifice their finer sensibilities, their normal compassion 



Il8 CARE OF THE INSANE 

for pain and mental torture is rapidly blunted, while 
their acquired indifference to the humiliation and pun- 
ishment they inflict upon irresponsible, helpless human 
beings brutalizes their nature and perverts their char- 
acter. Ex-employees have been known to boast of their 
cruel, fiendish treatment of weak but noisy insane 
patients twenty-five years after they left the hospital 
service. Mechanical restraint of the insane is so an- 
tagonistic to the spirit or principle which must pervade 
all rational schemes for controlling the insane that it 
should be totally abolished, or teaching " non-restraint" 
methods to nurses will avail little. The possibility of 
restraint lodged in the mind of the nurse smothers 
serious efforts to influence the patient by the charm of 
pity and the power of the intellect. 

It depends almost wholly upon the superintendent 
of each institution whether mechanical restraint is 
used in his hospital wards. The stand he takes upon 
this important question of management will be under- 
stood by all his subordinates and influence them in 
their dealings with the patients. If he is determined 
that restraint shall not be used, he will caution the 
whole hospital force of workers upon every convenient 
occasion. He will show his appreciation when they 
have managed cases well and repeat optimistic sugges- 
tions concerning their success if they ever waver in 



CARE OF THE INSANE 1 19 

their convictions. He should continually remind offi- 
cers and nurses that the secret of " non-restraint" — 
if there be any mystery regarding the question — 
consists in preventing or avoiding situations where 
restraint might be thought necessary by those who ap- 
prove its use. Those who argue that insane patients 
will take advantage of the milder methods of treat- 
ment and that an absence of strict discipline will re- 
sult — a condition which spells riot in their school — 
little appreciate the power that well-poised, properly 
taught, expert nurses can exercise over the insane by 
mental suggestion, calm persuasion and innocent arti- 
fice. Ward disorders can be more easily prevented by 
the judicious words of a quiet, self-possessed, gentle- 
toned nurse than by the threats and stormy commands 
of a ferocious keeper. A loud-talking patient can be 
quieted often by a polite request whispered in the ear. 
Because women nurses exhibit less show of force, avoid 
threats and stern commands, they manage patients in 
the male wards with less irritation and fewer outbreaks 
than occur when male attendants are in charge. For 
this reason female nurses should be employed in the 
male wards of hospitals as soon as a sufficient number 
of well-instructed, sensible women nurses can be ob- 
tained. Slender, light-weight girls have managed wards 
for excitable female patients quite as easily as women of 



120 CARE OF THE INSANE 

greater weight and strength because the smaller women 
had acquired the real art of managing insane patients. 
To be eminently successful in this work, a nurse ought to 
be endowed with some capacity for offhand romancing. 
Persons who cannot conceive of a well-behaved, fairly 
quiet ward of insane patients, without mentally exalt- 
ing the idea of discipline, used in its repressive sense, 
evidently are uninstructed or mistaken as to the char- 
acter and quality of measures most efficient in control- 
ling the insane. The medical superintendent of every 
hospital for the insane in the United States would no 
doubt gladly abolish mechanical restraint if he thought 
his employees could manage the patients without it. 
But employees never will control the insane by the 
" non-restraint" practice until they are taught the proper 
methods and have been compelled to adopt them, not 
only in the letter but in the spirit, which is far-reaching. 
Discharging or even imprisoning a few attendants guilty 
of serious assaults will not end asylum abuses. Inves- 
tigations by legislative committees cannot set up and 
supervise the only competent agency which will reduce 
to a minimum the hardships and wrongs needlessly in- 
flicted upon the insane in hospitals. The superintend- 
ent is the only person in the institution who possesses 
sufficient authority to adopt the " non-restraint" system 
of management and to enforce its observance. To sue- 



CARE OF THE INSANE 121 

ceed, he will have to spend much time over the details 
of difficult cases, as he cannot afford to have the nurses 
fail, and must therefore convince them of their inherent 
ability to succeed, and encourage perseverance. Nat- 
urally, some will succeed much better than others, and 
those who are doomed to failure through unfavorable 
temperament or inadequate power of application will 
voluntarily resign early in their experience. To keep 
some nurses from carelessness or mistakes will require 
deliberate watching and frequent aid with suggestion. 
When the superintendent appreciates their success in 
controlling irritable and violent cases and bestows mer- 
ited commendation as they improve with practice, the 
nurses are greatly helped and stimulated to do even 
better work. They will often depend upon his sym- 
pathy and encouragement to withstand the prolonged 
strain which some hard cases will cause. 

Dr. Conolly, who succeeded in managing the insane 
in accordance with " non-restraint" ideas, — something 
which so many other superintendents have deemed im- 
possible, — devoted a surprising amount of time and 
personal attention to each trying case in his hospital. 
He made repeated visits at night, as well as by day, to 
wards where troublesome patients were worrying the 
nurses. He thoroughly informed himself of the diffi- 
culties to be overcome in case after case, and of the 



122 CARE OF THE INSANE 

ability of properly trained nurses to master all possible 
situations, before he published his sweeping conclusion, 
viz., that "all insane patients can be managed without 
mechanical restraint" and that all superintendents who 
desire to conduct hospitals for the insane on the "non- 
restraint" plan "will succeed if they are in earnest." 
Results of so much consequence, both to patients and 
nurses, should not be sacrificed because officials lack 
earnest endeavor to pursue the methods by which alone 
they may be secured. 

To redeem the ward management of hospitals for the 
insane from the sway of untaught, rough and unsym- 
pathetic attendants means physical comforts, mental 
cheer and hopefulness to afflicted multitudes who are 
entitled to our compassion. To improve the under- 
standing and enrich the character of the great body of 
nurses in these special institutions is a worthy object 
and one of great promise. Primarily, the occupation of 
hospital nursing should be given an improved standing. 
Higher conceptions of its dignity and its educational 
possibilities should be held by officials and by them in- 
stilled into the minds of the ward workers. Ideals of 
devotion, self-sacrifice and humane service should be 
recounted for their benefit. Then the educational, sci- 
entific and humanizing acquisitions which will redound 
to the faithful student and the patient worker in this 



CARE OF THE INSANE 123 

field should be more widely understood. They should 
be taught to regard ward work in the light of laboratory 
experience in solving interesting and important prob- 
lems relating to science and humanity. Associated 
with this work there are some repugnant duties, some 
trying situations, but such objectionable features of the 
service can and should be minimized by contrasting 
them with the personal gains and the unlimited benefits 
which they bestow upon patients when the nurses are 
wisely and conscientiously discharging their hospital 
duties. If one expects to have nurses hold their posi- 
tions with such ideals in mind, he must extol the ad- 
vantages they will receive by pursuing such a course in 
training until they can read into humble duties the 
promise of higher things. There is much that can be 
adduced to prove that the submissive, painstaking nurse 
will be well repaid for devoted work. Her command of 
the English language will be improved by mastering 
lessons in text-books on nursing and by writing reports 
and examination papers. She will become well informed 
upon the laws of hygiene, learn how infectious diseases 
spread and are suppressed, understand the significance 
of pulse and temperature variations, — all practical mat- 
ters, the knowledge of which she can utilize to her per- 
sonal advantage through her life; or she can turn them 
to account by taking up private nursing as a career. 



124 CARE OF THE INSANE 

Graduate nurses, trained in hospitals for the insane 
where the correct " non-restraint" policy is enforced, 
meet with the greatest success in private nursing. Be- 
fore entering the field for family nursing, it is advisable 
for these graduates to take a supplemental course in 
some general or special hospital. But, with or without 
extra or special instruction and experience, their self- 
command, their readiness to meet the unexpected, their 
tactful methods with all persons, are accomplishments 
which they acquired in the hospital for insane and 
which will continue in evidence and will prove their 
best recommendation. After years spent with insane 
persons who have been held in check or stimulated into 
action and have been again and again turned from hasty 
or destructive purposes by her calm persistence, inven- 
tive genius and mental alertness, the nurse has devel- 
oped her latent mental capacity and force of character, 
and if normally well endowed will be able to adjust her- 
self to the temper of ordinary people or the caprice of 
sick folks without effort or delay. Nervous, peevish 
invalids are not puzzles to her. If the mood of the 
patient changes, she alters her mode of approach. If 
the patient is depressed and disconsolate, she avoids 
recalling matters concerning which the patient is sensi- 
tive by ignoring such subjects and promptly finding an 
opening for some interesting and optimistic suggestions. 



CARE OF THE INSANE 1 25 

If the patient is obsessed by some depressing reflection, 
the properly educated nurse eschews the words "Do 
not/' and all requests expressed by a negative phrase, 
because such phrases revive the unfortunate mental 
association. She quietly interests the patient's atten- 
tion in an opposite direction. She should never be at a 
loss for expedients suitable to serve her purpose. Such 
expert comprehension of the moods peculiar to invalids 
can be acquired nowhere else so quickly and so thor- 
oughly as in the wards of a hospital for the insane where 
mechanical restraint is never used or thought of. This 
consummate tact is the natural outgrowth of mental 
nursing when the nurse is deprived of all means by 
which to inflict penalties or punishments, and where she 
and the patients about her know that threats are idle 
expressions. 

Dispossessed thus of coercive power, under all circum- 
stances she must retain her presence of mind. She will 
have to appeal to friendly feelings, be able to interpret 
intentions rapidly and reach positive conclusions as 
quickly. She will also have to depend upon novel and 
fascinating schemes invented at a moment's notice to 
fit the requirements. She must remain calm when others 
are excited, must control her temper when tantalized, 
insulted or defied, and must accustom herself even to 
receive blows without showing resentment. In this work 



126 CARE OF THE INSANE 

the nurse can be aided by general rules only, because it 
is impossible to anticipate the exact conditions that will 
enter into any perplexing situation. No two patients 
are wholly alike, and the mental aspect of each patient 
varies with time and circumstances. Then, the per- 
sonality of the nurses will differ, each from the others, 
and all these variations in temperament and temper call 
for modifications in methods of approaching patients. 
Hence it is that only practice in such surroundings 
insures perfection in the art. To have acquired such 
an art means that the nurse who has mastered it has 
brought into working order all the mental resources 
with which she was endowed. She will then be fitted to 
measure her ability with that of any person with whom 
she may come into association — sane as well as in- 
sane. It is doubtful if any other established educa- 
tional course will, in the same length of time, better 
develop the practical capacity of a student nurse, or 
better fit her to cope with the struggle incident to her 
lifework. 

The same " non-restraint" kind of mental nursing is 
excellent practice for character building. It induces 
habits of self-discipline by necessitating deliberation, 
self-restraint, serenity under provocation, and the ha- 
bitual practice of good deeds in return for indifference 
and possibly evil intentions. To maintain their influ- 



CARE OF THE INSANE 127 

ence over the patients, nurses must be invariably kind. 
When a nurse considers the misfortune of the insane 
through compassionate eyes, her humane sentiments 
are cultivated. Scrutinizing mental wrecks, resulting 
from degeneracy, dissipation and disease, as nurses must, 
for some germ of manhood that may respond to the 
sunny influence of kindness, sympathy and good counsel, 
enables them to appreciate the better side of humanity 
in general. Pitying those who suffer from painful delu- 
sions as truly as though the cause for the anguish ex- 
perienced were genuine develops depth of feeling and 
emotions regulated by intelligence. 

Giving cups of water to thirsty but helpless patients 
and ministering to their many necessities with kind 
attention and a cheerful spirit reveals to the true nurse 
the one certain method by which personal happiness can 
always be realized. 

Such are the constant opportunities for exercising 
benevolent sentiments confronting every nurse in hos- 
pitals for the insane. 

If this moral and ethical phase of nursing were pre- 
sented in the right way and sufficiently often, the major- 
ity of nurses would respond favorably. From this point 
of view, nursing in hospitals for the insane calls for high- 
class work, approaching in many respects the heroic. 

The superficial impressions of nursing the insane 



128 CARE OF THE INSANE 

which freedom-loving youths and maidens usually ob- 
tain by entering upon the preliminary courses in train- 
ing schools are often repugnant, and few who enter the 
classes continue the work long enough to render intelli- 
gent service or to discover in its pursuit as an occupation 
much that is agreeable or satisfactory. 

Those who remain in the training school long enough 
to graduate generally do so because of the financial 
considerations only, and feel little inclination to con- 
tinue such exacting duties. If prevalent ideas concern- 
ing this important field of work could be radically 
changed for the better, if devotion to the service of 
mental nursing in hospitals commanded the interest and 
consideration it is entitled to receive when undertaken 
with intelligence in the right spirit, there might be re- 
tained permanently in hospitals for the insane an ample 
corps of serious-minded, faithful nurses who would act 
in obedience to the high sentiments and unselfish mo- 
tives befitting this ennobling occupation. Can such 
desirable ends be consummated? Can devoted nurses 
be so attracted to this worthy cause that they will 
intelligently undertake a lifework in behalf of those, 
many of whom are incapable of appreciation, and who 
often resist or blindly attack their best friends and bene- 
factors? Certainly not through coercive measures or 
restrictive legislation. Not until promptings to render 



CARE OF THE INSANE 129 

unselfish service to insane patients spring from the 
convictions and high sense of duty of the individual 
nurses. They cannot be frightened or effectually driven 
into the mental state that insures the right conduct 
towards patients any more than nurses can by force 
compel patients to effectively improve their manners. 

How to improve and elevate the grade of insane 
hospital nursing is a problem involving the action and 
reaction of human nature and the force of cultivated 
ideals. 

The work should be presented to nurses in attrac- 
tive, interesting terms comporting with high social and 
professional standards. Its importance, its dignity, its 
self-sacrifice and also its compensations should be ap- 
preciated and acknowledged in words and deeds by 
both hospital officials and an interested public. Nurses 
should be allured to this special field of devotion by a 
desire to share in the inherent glory which results from 
serving thankless insane patients for the cause of hu- 
manity. But this is a very practical age and few young 
persons are willing to sacrifice a life of commercial and 
social opportunity even for so high and humane a calling. 

As a rule, good nurses cannot be expected to ignore or 
reject more tempting emoluments offered them for nurs- 
ing the sane sick in private families or for some less 
exacting business occupation. Teaching the act of nurs- 



130 CARE OF THE INSANE 

ing the insane in hospitals and inculcating the ethics 
involved to small classes in scattered institutions are 
laborious duties devolving upon hospital officials; and 
when the comparatively meager results are considered 
in connection with the broader field of hospital require- 
ments, the necessity for educational centers with a 
broader foundation and a wider reaching influence, en- 
thusiastically engaged in this work, is clearly appre- 
hended. 

For this end, state commissions would act wisely in 
establishing schools for high-class instruction in nursing 
the insane. 

Some religious or benevolent order that would duly 
heed the scientific and practical aspects of the work 
would, if engaged in this line of service, accomplish great 
good. If a national guild or non-religious society of 
nurses engaged in caring for insane patients could be 
formed and maintained with a chapter in each hospital, 
officered and conducted by the nurses themselves, hav- 
ing a simple ritual and the literature necessary to keep 
before them high ideals of nursing and calculated to 
foster enthusiasm for the work, it is possible that the 
right ideas and the right spirit could be more widely 
and more rapidly disseminated. Such an organization 
should have a central bureau of administration, with 
proper officers to regulate its work and agents to super- 



CARE OF THE INSANE 131 

vise the work of the chapters. Graded ranks should be 
established, and promotions from rank to rank should 
depend upon personal character, length of service and 
acquired proficiency in the art of managing insane 
patients. A system of marking for rewards and pro- 
motion should be entrusted to the chapters, but all 
reports should require the indorsement of the local hos- 
pital officials before filing for subsequent use. To be 
entirely successful, such a central organization should be 
started with a substantial foundation, having sufficient 
funds to manage affairs, to provide insurance for loss 
of time in sickness, an old-age pension, and medals or 
gratuities for special meritorious acts. If a monthly 
compensation could be granted members of the higher 
circles, it would promote ambition to rise in the order. 
A scheme of this character would in no way antagonize 
the local management of hospitals, and would, no doubt, 
be sanctioned by all superintendents and aided by them, 
as it would mitigate their responsibility. Its members 
and agents should avoid criticizing hospital manage- 
ment except to the officials interested. The order should 
be animated by that philosophy which inspires efforts 
through presenting patterns of excellence in nursing the 
insane. Possibly hospital managers would gladly pro- 
mote the work by establishing a liberal scale of wages 
depending upon the rank attained by the employee. Of 



132 CARE OF THE INSANE 

course, all members should hold and wear, when on 
duty, badges representing the grade to which they had 
advanced. 

This is a most worthy object, as it is calculated to 
benefit two greatly neglected classes of human beings 
which will never diminish in number, — the insane and 
their custodians. The insane have an acknowledged 
claim upon our sympathies, while the daily but unher- 
alded acts of genuine heroism displayed by true nurses 
in hospitals for the insane deserve some official recogni- 
tion, and must receive it if the examples of such devotion 
are to be imitated in sufficient numbers to cover the 
field of necessity. 



APPENDIX. 

After the main section of this book was written 
friendly critics advised the introduction of concrete 
illustrations — a description of actual cases — which 
would supply clues to the methods by which the rules 
and suggestions advanced might be applied. The fol- 
lowing account is deemed too long for] insertion in the 
theoretical text. One or two episodes in the experi- 
ence of a patient will serve to illustrate how force and 
mechanical restraint can be avoided in managing 
patients, especially manic cases where exhilaration of 
spirits is associated with flighty and expansive ideas. 

The case of a man in middle life suffering from attacks 
of recurrent maniacal excitement may be cited. This 
patient had passed through several previous attacks, 
each characterized by such restlessness, abnormal de- 
grees of self-assertion and unreasonable conduct that 
hospital restrictions had been necessary. 

Each time he had been committed to the same hos- 
pital, where he had established a reputation for cunning, 
incorrigibility and destructive capacity. With insignifi- 
cant instruments he had accomplished surprising results 
through shrewd, persistent efforts. For nights and days 
in succession he seemed to require no sleep, and re- 

133 



134 CARE OF THE INSANE 

peatedly destroyed clothing, furniture and fixtures. Al- 
ways intent upon escape from the hospital, ever ready 
with plausible, ingenious explanations for his conduct 
when interviewed by officials, and remarkably skillful in 
distorting facts to impeach his attendants, he became 
the object of their dread and hatred. He never lost his 
temper, usually joked and laughed when restrained by 
strait-jackets, and was reported to have once remarked, 
when able to catch his breath while being subjected 
to the " water-cure treatment/' "Boys, you are on the 
right track. The devil is in me and you may drown 
him if you keep on." When subjected to such rigid 
measures he often expressed satisfaction, saying his was 
a detective's mission and he was anxious to experience 
the worst, as he contemplated publishing a book expos- 
ing insane hospital barbarities. 

The care of this patient was a burden to the manage- 
ment, and in time arrangements for his transfer to a 
similar institution in another state were perfected. A 
junior assistant physician who at an earlier period had 
for a time held some official relations with the patient 
volunteered to conduct the transfer. The patient, by 
his mental alertness, endless schemes and good-natured 
acceptance of the inevitable, had interested this young 
physician, who had experienced no difficulty in manag- 
ing him. Through a change in the service, about three 
months prior to the date of transfer, an older, more ex- 
perienced hospital physician had assumed entire charge 
of the ward in which this patient was located. Owing 
to the progress of the disease, or some other cause, the 



CARE OF THE INSANE 135 

patient's worst propensities developed and trouble with 
him was of almost daily occurrence. The night before 
the transfer he planned a campaign, probably an escape, 
and opened it by barricading the door of his room. 
When this fact was discovered by the night watch he 
considered the situation sufficiently grave to notify the 
physician in charge. The doctor's apprehensions re- 
garding this patient were such that he hastened to the 
ward and personally directed efforts to dislodge the 
maniac. After various milder measures had proved 
futile, at two o'clock in the morning the doctor pro- 
cured a crowbar and demolished the heavy door. The 
following morning at nine o'clock the junior physician 
and the patient set out for the other hospital, 160 miles 
distant. The doctor in charge of the hospital they left 
offered to send any desired number of strong attendants 
along to insure custody of the patient. When this offer 
was declined he urged the employment of one or more 
city policemen. When that proposition was rejected 
and he realized that no semblance of force was to be 
employed in the transfer, he predicted disaster to the 
enterprise. This recognized authority, who as medical 
chief had previously managed one of New England's 
most prominent hospitals for the insane during a period 
of two years, remarked, "It cannot be done; you will 
never get the patient into that hospital without help." 

The patient had in some measure been prepared for 
this trip. With this object in view, the junior assistant 
had visited his ward several times, had expressed re- 
grets that the patient had become involved in so much 



136 CARE OF THE INSANE 

friction with employees and officers, and in low, confi- 
dential tones had predicted that a time would come 
when they two could leave the hospital together. When 
they were finally outside the institution the physician 
raised the question of their destination. The patient's 
sense of gratitude upon finding himself so free no doubt 
prompted the response that he would be wholly guided 
by his companion's judgment. Whereupon the latter 
suggested a trip to a distant city, where in the suburbs 
was located the hospital that had engaged to receive 
and care for the insane man. By good fortune it hap- 
pened to be election day in the city which was their 
destination. The patient's well-known weakness for 
detective honors supplied a key to the doctor's scheme 
of procedure and a text for earnest discussion the live- 
long day. The glittering rewards for that detective 
skill which could expose crooked political ways were 
considered and reconsidered. As they journeyed along, 
newspapers were purchased at every opportunity and 
their columns were eagerly scanned to discover predic- 
tions of fraudulent voting and suggestions of bribery. 
By such devices the patient's attention was kept fully 
engrossed. They finished their day's railroad trip early 
in the evening. All voting places were closed, but 
crowds of expectant men were gathered before public 
bulletin boards and in hotel offices. After mingling 
with several small groups in succession, they sought a 
public house for supper. Later they started out again 
and without arousing the patient's suspicion the doctor 
gradually led the way to the outskirts of the city and 



CARE OF THE INSANE 137 

finally discovered the entrance to the hospital. He 
assumed much surprise upon finding himself so near the 
good doctor who superintended the institution and im- 
mediately resolved to call upon him and invited the 
patient to go along as his friend, assuring him that they 
would receive a cordial welcome for the night in virtue 
of his official connection with an institution of the same 
class. 

The patient balked. He refused to go into the hos- 
pital, but stood and listened to the doctor's exhorta- 
tions, which pointed out the folly of neglecting such 
an opportunity to exercise his detective ability, such a 
chance to peer into hospital secrets, and extolled their 
good fortune in stumbling into another promising field 
for investigation just when they had completely failed 
to make good in connection with political games. Then 
the patient's long-cherished project of exposing hospital 
abuses was recalled, and the importance of gaining a 
wide and varied experience before attempting to formu- 
late general conclusions was emphatically dwelt upon. 
The idea that his version of hospital management, or 
mismanagement, would attract more than local interest 
if his published observations were limited to a single 
institution was derided. It was admitted that he as- 
sumed some risk in entering, but to conceal his identity 
and limit the hazard of being detained as a patient 
a slight change in his name was suggested. His fam- 
ily name chanced to be a compound word, and he was 
advised to use the initial instead of the first two syl- 
lables and adopt the last word as his surname. For a 



138 CARE OF THE INSANE 

long time they stood before the administration building 
while such suggestions were hurled at him and his ob- 
jections were discussed. Apparently nothing the doctor 
said influenced him. He seemed determined to go no 
farther. Finally he said, "You go in and spend the 
night with the superintendent. I'll go back to the 
city and meet you in the morning." The doctor, with 
a suggestive inflection, answered, "Yes, if you are able 
to find me to-morrow," and turning about deliberately 
walked towards the hospital. 

Before taking the train at the railroad station in the 
morning, the doctor had purposely slipped out of the 
patient's sight for a short time apparently wholly in- 
different regarding further companionship with him. 
This movement early disarmed any lurking suspicion the 
patient may have entertained, and through the whole 
day up to this time he had simply dogged the doctor's 
footsteps. 

And now at this critical juncture was a similar ruse 
going to be effectual? There was great uncertainty, 
and the doctor was seriously anxious for a time as he 
advanced along the walk without hesitation or back- 
ward glances. By the time he had covered fifty feet 
the mental strain relaxed, as he distinctly heard the 
patient's peculiar step approaching in his rear. The 
patient had a round bald head with a full face, a large- 
sized body, very muscular and well knit; but his legs 
were abnormally short, much bowed and of unequal 
length, consequently his footfalls always resounded like 
an irregular tattoo, so unusual that once heard they 



CARE OF THE INSANE 139 

could never be forgotten. The distance between them 
gradually lessened and practically closed as they en- 
tered the institution reception room, where a supervisor 
was in waiting, and addressed the doctor by name. 
The doctor immediately introduced the patient as his 
friend and requested he be shown a quiet room at once, 
explaining his seeming haste on the ground that they 
had passed a fatiguing day and that his friend had been 
unable to sleep the previous night. "What is the pa- 
tient's name?" asked the supervisor. Immediately he 
shifted the weight of his body from the short leg, his 
usual pose, to the longer limb, thus presenting a bolder 
attitude, and elevating his chin to better typify his 
sense of self-importance he gravely enunciated the abbre- 
viated name so recently devised. With a simple good 
night they separated and, so far as the physician antici- 
pated, never to meet again. Naturally the physician 
was gratified with the success of his stratagem; many 
of his projects having been adopted suddenly to meet 
unexpected conditions or to gain advantage by follow- 
ing chance suggestions, he never suffered any conscien- 
tious scruples concerning the ethics of his conduct, 
although admitting that as a rule employing decep- 
tion in committing the insane to hospitals cannot be 
approved. 

The circumstances surrounding this case were so un- 
usual the methods employed seemed justifiable. The 
patient was not being removed from his own home — 
from kindred or trusted friends. He was leaving an 
institution where his presence was deplored and some 



140 CARE OF THE INSANE 

of his experience had been bitter. He was placed in 
a hospital famed for the consideration shown its pa- 
tients, and introduced to new associations where preju- 
dice against him was non-existent. He was fully in- 
formed respecting the character of the institution which 
he voluntarily entered, and he was not misinformed re- 
specting his ability or inability to extricate himself. 
He was misled in some respects, but he was not the vic- 
tim of naked falsehoods. When alternative measures 
are considered, the mercy of the successful plan is obvi- 
ous. Had this transfer been conducted by policemen, 
he would have been exposed as a culprit to crowds of 
people along the way and probably would have been 
unnecessarily stigmatized by wearing handcuffs. Had 
hospital attendants been utilized as guards, he would 
have suffered constant irritation, would have attempted 
escape or would have offered resistance, and few men 
were his equal as regards physical strength or power of 
endurance. 

Perhaps it would be more interesting, if less impor- 
tant, to learn how the patient regarded the doctor's 
proffered friendship. Did he treat the affair as a joke, 
or did he revolt, nurse his wrath and resolve to be re- 
venged should opportunity offer? The sequel will suffi- 
ciently answer such questions, for, curiously enough, 
they subsequently met and resumed the masquerade. 

While on a vacation trip two or three years later the 
assistant physician spent a few days in New York City. 
The then new post-office building, architecturally con- 
spicuous in City Hall Park, attracted his attention on 



CARE OF THE INSANE 141 

one occasion. Having ample time to indulge his fancy, 
he entered and sauntered through its spacious corridors 
admiring their massive elegance. He thus inspected 
several stories in succession. Ascending the broad stair- 
case to the upper floor, he casually glanced upward and 
beheld, to his great surprise, standing calmly on the 
edge of the landing, his old patient and companion for a 
memorable day's travel, whom he had neither seen nor 
heard from after the hospital door had closed shut be- 
tween them. With an exclamation of surprise and great 
interest he advanced to complete the usual form of 
greeting, but his quondam partner in simulation held 
himself in reserve. With a mien of the traditional 
North American Indian he deliberated for a time, and 
then drawled out, "I don't know about you. I am in 
no haste to resume acquaintance with a man who played 
me such a trick as you did." The doctor expressed re- 
gret that their past relations were susceptible of such 
opposite interpretations as his own views and those held 
by the patient. He begged a reconsideration of the 
whole affair and gradually compelled the patient to ad- 
mit the transfer had been made imperative by other 
parties — that those responsible for the change would 
have planned the trip without the slightest considera- 
tion of the patient's comfort or feelings and would have 
publicly subjected him to humiliation by a conspicu- 
ous exhibition of police or hospital authority. He also 
acknowledged he was much more kindly treated at the 
latter hospital and ought not to treasure up resentment 
against one who voluntarily and without personal profit 



142 CARE OF THE INSANE 

had actually saved him much annoyance, possibly physi- 
cal suffering, and had favorably changed the drift of his 
experience. 

When this debatable point in their previous alliance 
had been thoroughly exploited, the doctor asked when 
and how he had left that northern hospital, how he 
happened to be in New York City, and what he pro- 
posed to do. Answers to a few such questions enabled 
the doctor to fully comprehend the situation. The pa- 
tient had been well treated at the last hospital, but one 
night, after about six months' residence, he had quietly 
slipped out of the building, determined to walk home. 
It being the autumn season, he readily found employ- 
ment with farmers along the route, working a few days 
in each of several places, and finally reached home in 
good condition with surplus cash in his possession. His 
mental condition had changed with time, and when he 
met his relatives he presented the subacute reactionary 
stage of his mental cycles, and being a bachelor he was 
welcomed by his brother who lived at the old home- 
stead. He had remained there more than two years, 
quiet and agreeable to all. He had undoubtedly made 
himself useful about the house and in the garden. But 
now his periodical mental ebullition was in evidence, re- 
flecting his emotional intoxication. His prolific fancy, 
disregarding logical bounds, involved him in chimerical 
schemes. Again he was in his own imagination a mas- 
ter detective. He declared he was a secret-service man 
in the employ of the United States government. He as- 
serted that serious affairs on the Pacific Coast required 



CARE OF THE INSANE 1 43 

his immediate attention and presence, and that he must 
start for California not later than the following morn- 
ing. He had been disappointed in trying to find the 
office of the government transportation agent, although 
a gentleman in the street had directed him to the upper 
floor of the post-office building. Thus came about this 
accidental meeting which neither party anticipated or 
desired. 

As the history of mental disorder, such as was repre- 
sented by the patient, concerning both the delusions 
entertained and the personal conduct, repeats itself, the 
doctor instantly realized that the patient had relapsed, 
had surreptitiously left home, and that his relatives 
must be anxious regarding his whereabouts and his 
welfare, and that measures to protect him ought to be 
promptly instituted. The doctor's recollection of the 
patient's history embraced the fact that a nephew was 
a New York City business man, and a call upon him was 
proposed. The patient emphatically refused to have 
anything to do with his relatives. But at length he so 
far yielded to continued persuasion that he named the 
street and number but seemed most unwilling to ven- 
ture there. Yet an hour's pleading did prevail, and 
eventually he led the way, only a short walk, to the 
office of his only brother's son. 

The young man was agreeably surprised to see his 
uncle enter his presence, but for a time he regarded the 
doctor with suspicion, not readily accepting the ex- 
planation of attending circumstances; being unable to 
comprehend why a stranger to him should from disin- 



144 CARE OF THE INSANE 

terested motives come there with this man whose ner- 
vous manner and flighty conversation stamped him as 
decidedly peculiar. Soon he ushered his uncle into a 
private room, and, leaving him there after a long con- 
versation, he interviewed the doctor. After repeated 
conferences of that order, and finding that each visitor 
confirmed the other's statements, and that his own fam- 
ily history was well known by the doctor, he accepted 
in good faith the claim that the doctor, knowing the 
patient, appreciated the condition in which he found 
him and simply wished to deliver him to his relatives. 
The young man then expressed his appreciation for the 
service rendered and drew from his pocket a telegram 
which read as follows, viz. : " Reuben has gone on another 
tear; he ran away from home. Will probably go to 
New York. If he turns up there have him arrested and 
confined on the Island until I can arrange his commit- 
ment to the Retreat." 

The message was from his father, who was a physi- 
cian, and the son proposed to act upon it literally, and 
at once, by handing his uncle over to the city police. 
Such an unpleasant termination to a call which was 
the result of his solicitation had not been anticipated 
by the doctor, and he strenuously objected to the plan. 
Then followed a long discussion upon future manage- 
ment of the patient. Various expedients were sug- 
gested, but all met with objections. The nephew would 
not go with his uncle. He felt he could not leave his 
business, and admitted he lacked the necessary courage 
to undertake even temporary management of the case. 



CARE OF THE INSANE 1 45 

In time the patient was admitted to the conference. 
The doctor plainly told him their convictions that he 
ought to go to the hospital for care and treatment. Of 
course he protested at first, but his opposition to the 
plan faded as the doctor pointed out the improbability 
of Ins success as a political detective and assured him 
that his earlier conception to reform insane hospitals 
was a much more promising proposition ; that much of 
hospital life and methods remained unknown to him; 
that he ought to witness how a change in hospital man- 
agement could alter ward conditions and note how 
changed the life of patients became when the old coer- 
cive practice was no longer the rule; that he ought to 
revisit his old hospital haunts and compare present con- 
ditions with such as he had formerly encountered there; 
that, with the exception of the informant, every officer 
in the hospital as he knew it had gone and new men 
now filled the positions. The patient became so much 
interested in this suggestion that he offered to return 
with the doctor. The doctor regretted he could not 
cut short his vacation to accommodate his old friend, 
whereupon the patient complacently announced that it 
would be entirely agreeable to him to remain in New 
York until the physician's vacation expired. This con- 
cession on his part could not be favorably entertained. 
While puzzling over the difficulties to be met, the doctor 
had an inspiration and taking the patient aside suggested 
he go alone to the hospital. The boldness of this pro- 
posal strongly appealed to his imagination. The doctor 
elaborated the proposition. He proposed giving a let- 



146 CARE OF THE INSANE 

ter of introduction to the new superintendent, asking 
him to receive the assistant's old friend and former 
patient and treat him like a guest until the assistant's 
return. He finally confided to the patient the contents 
of the telegram he had just read, showing that the 
brother and nephew would insist upon his commitment, 
and that the police would be requested to arrest him if 
he left their presence; that, once in the hands of the 
police, there would follow court proceedings, temporary 
jail residence and ultimately a journey to the hospital 
under the espionage of rough policemen. Why not with 
this warning and such an opportunity give his family 
the surprise of their lives — why not checkmate them in 
the game they were playing! The audacity involved 
in executing such a counter move was too captivating 
for him in his peculiar state of mind to resist, and he 
eagerly responded, "I'll do it." 

The nephew was then informed that all difficulties 
had been solved and the terms of the capitulation were 
imparted to him. He regarded the arrangement as 
decidedly visionary and refused his sanction. The doc- 
tor defended the plan and assured the nephew that the 
patient, having given his word of honor, could be de- 
pended upon to fulfill his agreement. To be upheld as 
a man of honor before his doubting relative and by the 
assistant physician of an institution where as he knew 
his name had usually been regarded as synonymous 
with perfidy, flattered his vanity, of which he always 
retained a good measure, especially when in his elated 
moods, and he became eager to substantiate the doctor's 



CARE OF THE INSANE 147 

prediction concerning his reliability. "Will you hon- 
estly do it?" asked the nephew. "Yes," responded the 
patient. "The doctor hoaxed me once, but no matter, 
I'll go anywhere he says, if it is to h — 1." 

Misgivings still lingered in the nephew's mind. As 
he started with his uncle for the 42nd Street Station, 
turning aside he remarked to the doctor, "What will 
father think of me if uncle breaks his promise? Now 
we have him in our power, it doesn't seem sensible to 
trust him alone." Nevertheless he duly performed his 
assigned part. He saw his uncle off in the train for 
Hartford with a through ticket in his hand. Messages 
and letters were dispatched to the hospital authorities 
announcing the coming of the patient and requesting 
his safe custody until relatives could perfect arrange- 
ments for his continued treatment. This "irrespon- 
sible" man kept his agreement in every particular. 
When he left the train he entered a public carriage and 
ordered the driver to convey him to the Retreat. Upon 
reaching the institution he hurried into the business 
office and requested the clerk to pay the hackman and 
charge the amount to him. He then presented his letter 
of introduction to the new superintendent and was 
assigned a room in the patients' department, where the 
assistant found him on his return. 

For several years he remained at the hospital as a 
patient, but never afterwards did he attempt to escape. 
Nor did he become involved in serious difficulties with 
employees or officers. His relations with the doctor 
who induced him to return to the hospital from which 



148 CARE OF THE INSANE 

his former deliverance had seemed to him like a tri- 
umph in the thick of calamities continued most cordial 
to the end. The revolution in his hospital conduct 
may be largely credited to the consideration he received 
and the freedom he enjoyed during this his last sojourn 
there. Instead of being constantly regarded with the 
irritating suspicion of tactless keepers, as in former 
days, he escaped such thralldom by having parole of the 
premises, or the city, the greater portion of the time. 
Whereas in previous attacks he had been confined to 
narrow quarters as a rule, being frequently locked in a 
strong room to expiate past misdeeds, or to forestall his 
aggravating pranks, which, it must be confessed, some- 
times degenerated to the level of malicious mischief, he 
was now at liberty to work off his abnormal energy in 
walking about the country. Instead of restrictions in 
numberless ways which had been his former lot, he was 
permitted to busy himself in the garden, and for a time 
he canvassed the city for the sale of some book or 
kitchen device. Hence he came to look upon the hos- 
pital as less a prison and more his hotel. 



CARD INDEX 



In hospitals for the insane the card index is no doubt 
generally utilized for convenience of reference in ordinary 
business matters. But comparatively few institutions, 
it is believed, keep a card index of all important facts to 
be found in the case records. 

Unless such records, already voluminous in some hos- 
pitals, are made available through a classified card-index 
system, the vast amount of high-class professional work 
being done and recorded in the leading institutions, can- 
not be utilized for scientific papers and generalization; 
ends too important to be ignored. 

If the task of indexing back records seems too formi- 
dable to be undertaken, certainly current records should 
be so kept that all essential points could be easily noted 
in a card index. 

By providing for each case an index sheet bearing a 

printed list of all important symptoms of nervous and 

mental diseases as well as a classification of insanity and 

vital facts incident to personal histories, the assistant 

physician can easily check the appropriate terms in such 

149 



150 CARE OF THE INSANE 

an index as the history and hospital development of 
patients become familiar. 

The checked index on the individual sheets can at 
convenient intervals be transferred to a card-index sys- 
tem by office clerks. 

Blank space on the case-index sheet should be provided 
upon which may be written features special to any one 
case as may be required. When individual case port- 
folios are provided for all patients the index sheet is filed 
with the other papers, therefore it is advisable to use 
colored paper for such sheets so identification may cause 
no delay. 

When a superintendent attempts to keep control of 
hospital discipline, the card system would seem to be 
a necessity. Otherwise many minor troubles entirely 
escape his attention ; a condition which should not be al- 
lowed if the more serious affairs are to be avoided. For 
the purpose of keeping posted upon ward friction, cards 
should be kept in every ward for use in reporting all 
instances of trouble with a patient. The employees 
should understand that they must fill out a card promptly 
under conditions stated on the card, viz. : when a patient 
escapes, attempts to escape, receives an injury, by acci- 
dent or otherwise, has to be handled with force, or is 
secluded. The card should then be given at once to the 
assistant physician for his signature and he should turn 



CARE OF THE INSANE 151 

it over to the superintendent. At his early convenience 
the superintendent can take the card to the ward and 
institute a private investigation sufficiently thorough to 
satisfy himself as to the responsibility of the several 
parties. 

He can then make his decisions and write comments 
on the back of the card and file it under the name of 
the patient. If complaints of the treatment of patients 
are made to him in his office, such memoranda at hand 
will afford him satisfaction and assure the complainant 
that the patient is not being neglected. By this method 
a superintendent can keep himself posted upon all the 
bad history the hospital is making — just the things 
most essential for him to know. 

Besides learning at once if the attendant has shown 
the right spirit in the incident reported and demon- 
strated good sense in managing the affair, such interviews 
as must follow each report can be made the occasion for 
a private lecture to the employee in which the impor- 
tance of managing the patient with skill instead of through 
threats and force can be enlarged upon. Even when the 
trouble is of little consequence, the employees usually 
will be more thoughtful before getting involved again, 
as they soon dread the pointed instruction which is their 
due under such circumstances. 

When such a reporting system is established, neglect 



152 CARE OF THE INSANE 

to make a report should never be excused. If a report 
is withheld by the nurse, the chances are that some 
patient will remind the superintendent, the first good 
opportunity, that something occurred which should have 
been reported. They get so accustomed to his investi- 
gations that they suspect something has gone wrong if 
he does not appear soon after troubles occur to quiz the 
patient and attendant. The admonition, telling what 
to report, may be printed in small type across one end 
of the cards. 

If a superintendent desires to aid his medical staff in 
acquiring a thorough knowledge of psychiatry, and 
make the study interesting, he can promote that object 
by providing and maintaining a card index of the litera- 
ture of insanity as found in standard works on the sub- 
ject, and in current periodicals in English, German and 
French. Where the daily clinic is practiced, and where 
the cases are carefully analyzed, such an index will enable 
the whole faculty to obtain and utilize a broad knowledge 
of insanity. For this purpose the cards should not be 
used for quotations so much as for a concise typewritten 
statement in English of the writer's claim or argument, 
the point made, or the fact stated. The aim should be 
to epitomize without losing the writer's point of view or 
misstating his conclusions. Good judgment and discre- 
tion must be exercised to avoid putting second-hand and 



CARE OF THE INSANE 153 

worthless statements on the cards. Borrowed ideas and 
restatements, of no scientific or controversial worth, 
should be ignored. 

Single cards should carry single ideas only. When 
authors bring together different subjects or different 
phases of one subject, the several items should each 
have its card to be filed in its appropriate place. 
Otherwise, one searching for information on a given 
point might be unable to find the correct card. When 
the information to be indexed is of uncertain bearing 
or of doubtful application, duplicate cards can be made, 
each filed in separate sections under the right guide 
card. 

In order to file cards so that each one is quickly avail- 
able as occasion may desire, a comprehensive scheme for 
fifing must be elaborated, and a copy kept at hand to aid 
in phrasing the card as well as in filing it. In the card 
drawers a word must serve as a guide, and this word 
should be kept in mind when the abridged card content 
is dictated or written. 

The subject of Insanity should be divided into great 
divisions such as historical, etiology, symptomatology, 
diagnosis, prophylaxis, pathology, treatment, medico 
legal, etc. Each division should be divided into sub- 
divisions, and subdivisions into heads, and heads into 
subheads, so the guide cards will embrace all conceivable 



154 CARE OF THE INSANE 

points upon which information concerning insanity may 
be found. Under the several major divisions, heads and 
subheads may be duplicated. 

Every physician can keep a card index of his reading, 
and, if that is not extensive, a simple arrangement of 
cards may answer. But hospitals for the insane ought 
to have a complete summary of the literature upon 
insanity, and in order to make it thoroughly practical a 
very complete system of guide cards should be formu- 
lated in advance. A form should be printed on each 
card to assist in filing and in sorting if accidentally mixed. 
The department or division should stand out conspicu- 
ously. The author's full name should always occupy 
the same position on the card. The date of the publi- 
cation, as well as the title and page, should be clearly 
stated. If a journal, the name, year, number and page 
should be given. As duplicate cards could be filled in at 
comparatively little additional cost, it would seem advis- 
able for the several hospitals in a state, or from a wider 
district even, to combine in the preparation of such an 
index. There is nothing chimerical in this proposition for 
a broad card system covering the whole field of literature 
on insanity. Indeed, such a card system pertaining to 
tuberculosis has been devised and brought down to date 
by an eminent specialist,* who has managed a private 
* Dr. Karl von Ruck, Asheville, N. C. 



CARE OF THE INSANE 1 55 

sanitorium and attended to much outside business while 
perfecting such an index, which now has about 13,000 
guide cards. 

The owner has either signified what the contents of 
the cards should be, or, when assistants have been en- 
gaged in making cards, he has inspected each one before 
it was filed. 



APR 26 1912 



